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CLINICAL   PSYCHIATRY 


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CLINICAL    PSYCHIATRY 

FOR   STUDENTS   AND   PHYSICIANS 


ABSTRACTED  AND  ADAPTED   FROM  THE 
SEVENTH   GERMAN  EDITION   OE 

KBAEPELIN'S   "LEHKBUCH  DEE  PSYCHIATRIE  " 


BY 

A.    ROSS   DIEFENDORF,   M.D. 

LECTUBEB    IN    PSYCHIATRY    IN   TALE    UNIVEBSITY 

MEMBEE    OP    THE    AMERICAN    NE0BOLOGICAL   ASSOCIATION,    OF    THE 

NEW    YORK   NEPHROLOGICAL    ASSOCIATION,    OF    THE    NEW    TOBK 

PSYCHIATRICAL    SOCIETY,    AND    OF    THE    AMERICAN 

MEDICO-PSYCHOLOGICAL    ASSOCIATION,    ETC. 


NEW  EDITION,   REVISED  AND   AUGMENTED 


THE   MACMILLAN   COMPANY 

LONDON:  MACMLLLAN  &  CO.  Ltd. 

1915 

AU  rights  reserved 


Copyright,  1902,  190T, 
Bt  THE   MACMILLAH   niMPANT. 

Set  up  and  electrotyped.     Published  May,  1902.     Reprinted  Apnl,  1904. 
New  edition,  May,  1907  ;  August,  191a;  March,  1915- 


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J.  8.  Cushing  &  Co.  —  Berwick  &  Smith  Co. 

Norwood,  Mass.,  U.8.A. 


PREFACE   TO   THE   FIRST   EDITION 

The  motive  for  this  work  was  to  make  the  teachings 
of  Kraepelin  in  psychiatry  accessible  to  American  medical 
students  and  general  practitioners,  and,  at  the  same  time, 
to  provide  a  full,  but  concise,  text-book,  not  only  for  the 
writer's  own  classes  in  psychiatry  in  the  Medical  Depart- 
ment of  Yale  University,  but  as  well  for  other  American 
teachers  who  follow  Kraepelin' s  views.  Urged  by  the 
rapidly  increasing  interest  in  Professor  Kraepelin's  teach- 
ing during  the  past  five  years  in  this  country  and  the 
constantly  growing  number  of  his  disciples,  it  was  the 
writer's  first  intention  to  publish  a  complete  translation 
of  the  sixth  edition  of  Kraepelin's  "  Lehrbuch  der  Psychia- 
tric" It  was  feared,  however,  that  a  full  translation 
would  be  too  large  to  best  subserve  the  function  of  a  text- 
book, and  would  have  rendered  impossible  the  adaptation 
of  the  Kraepelin  psychiatry  to  our  peculiar  American 
needs. 

The  classification,  terminology,  and,  wherever  possible, 
the  phraseology  of  this  work  are  Kraepelinian,  but  the 
writer  haa  takep  the  liberty  of  abbreviating  dispropor- 
tionately the  description  of  some  psychoses  which  are  of 
less  importance  to  the  American  physician,  especially  the 
constitutional  psychopathic  states  and  thyroigenous  in- 
sanity, and  of  laying  more  stress  upon  other  more  impor- 
tant forms,  the  description  of  acquired  neurasthenia, 
traumatic  neuroses,  also  the  treatment  in  epileptic  and 
hysterical  insanity  and  acquired  neurasthenia. 


vi  PREFACE   TO   THE   FIRST   EDITION 

The  only  omissions  are  the  general  etiology,  diagnosis, 
and  treatment  in  the  first  volume  of  Kraepelin,  but  such 
points  as  are  of  most  importance  have  been  added  to  the 
etiology,  diagnosis,  and  treatment  of  the  different  diseases. 

The  work  has  been  done  in  the  pressure  of  routine 
duties  as  Assistant  Physician  and  Pathologist  of  the 
Connecticut  Hospital  for  the  Insane,  and  the  writer  begs 
leave  to  express  in  this  place  his  grateful  appreciation  of 
the  generous  advice  and  help  of  his  colleagues  in  the 
hospital,  especially  Dr.  Charles  W.  Page.  He  is  particu- 
larly indebted  to  Dr.  J.  M.  Keniston  for  a  general  revision 
of  the  text  as  well  as  for  the  arrangement  of  the  chapter 
on  Epileptic  Insanity,  to  Professor  Raymond  Dodge,  Ph.D., 
of  Wesleyan  University,  for  criticism  and  suggestion  with 
regard  to  the  general  symptomatology,  and  to  Dr.  August 
Hoch  and  Adolf  Meyer  for  their  continued  inspiration  and 
critical  assistance. 

A.  ROSS  DIEFENDORF. 

MlDDLETOWN,    CONNECTICUT, 

January  15,  1902. 


PREFACE   TO   THE   SECOND   EDITION 

The  favorable  reception  of  the  first  editions  of  Clinical 
Psychiatry  and  its  constantly  increasing  use  as  a  text-book 
encouraged  the  writer  to  undertake  a  thorough  revision 
based  on  the  seventh  edition  of  Kraepelin's  "Lehrbuch 
der  Psychiatrie."  In  accord  with  the  present  views  of 
Professor  Kraepelin  there  are  introduced  many  important 
changes,  both  in  the  general  symptomatology  and  in  the 
description  of  the  forms  of  mental  disease.  For  the  con- 
venience of  students  the  chapter  on  Methods  of  Examina- 
tion is  amplified  by  explicit  practical  suggestions  adapted 
to  the  circumstances  under  which  most  of  them  will  be 
compelled  to  work,  while  the  more  elaborate  procedure  of 
the  modern  experimental  laboratory  has  been  omitted. 
In  response  to  a  general  demand,  an  abridgment  of  the 
chapter  on  the  Classification  of  Mental  Diseases  is  added 
to  the  present  edition.  Less  hampered  by  restrictions  as 
to  size,  the  present  edition  follows  more  closely  the  con- 
text of  the  "  Lehrbuch."  The  description  of  the  more 
important  forms  of  insanity  is  less  curtailed,  while  the 
psychogenic  neuroses  and  the  psychopathic  states  which 
received  scant  attention  are  now  given  fuller  considera- 
tion. The  chapter  on  Psychopathic  Personalities  did  not 
appear  in  Kraepelin's  earlier  edition.  The  writer  has 
tried  to  make  it  clear  by  references  wherever  additions 
of  his  own  have  been  made.  The  most  important  addi- 
tions without  explicit  references  occur  under  the  head  of 
Treatment. 


viii  PREFACE  TO  THE  SECOND  EDITION 

As  in  the  preparation  of  the  first  edition,  the  work  has 
been  done  under  pressure  of  routine  duties  as  Assistant 
Physician  and  Pathologist  of  the  Connecticut  Hospital 
for  the  Insane,  and  the  writer  desires  to  express  to  his  col- 
leagues his  appreciation  of  their  help,  and  especially  to 
Dr.  Henry  S.  Noble,  Superintendent,  his  grateful  obliga- 
tion for  placing  at  his  disposal  the  time  and  much  of  the 
material  for  the  work.  He  is  under  special  obligations  to 
Dr.  J.  M.  Keniston  for  help  in  reading  proof  and  the 
arrangement  of  the  chapter  on  Epileptic  Insanity,  and  to 
Professor  Raymond  Dodge,  Ph.D.,  of  Wesleyan  University, 
for  criticism  and  suggestions  with  regard  to  the  general 
symptomatology  and  the  Psychopathic  Personalities. 

A.   ROSS  DIEFENDORF. 

MlDDLETOWN,  CONNECTICUT, 

April  6,  1907. 


CONTENTS 

GENERAL  SYMPTOMATOLOGY 

PAGB 

A.  Disturbances  of  the  Process  of  Perception 3 

Hallucinations  and  illusions,  perception  phantasms,  repercep- 
tion,  double  thought,  apperceptive  illusions,  reflex  halluci- 
nations, hallucinations  and  illusions  of  hearing,  sight,  taste, 
smell,  and  touch. 
Clouding  of  Consciousness     ........       14 

Befogged  states,  disturbance  of  apprehension,  retardation  of 
apprehension,  diminished  sensibility. 
Disturbances  of  Attention     .         .        .         .         .         .         .         .18 

Active  and  passive  attention,  blocking  of  attention,  dulling  of 
attention,  retardation  of  attention,  blunting  of  attention, 
passivity  of  attention,  distractibility  of  attention,  hyper- 
prosexia. 

B.  Disturbances  of  Mental  Elaboration 23 

Disturbances  of  memory,  disturbances  of  the  impressibility  of 
memory,  disturbances  of  the  retentiveness  of  memory,  dis- 
turbances of  the  accuracy  of  memory,  fabrication  of  memory. 
Disturbances  of  orientation :  time,  place,  and  person  dis- 
orientation ;  apathetic  disorientation ;  perplexity ;  delirious 
disorientation ;  amnesic  disorientation ;  delusional  disorien- 
tation. 
Disturbances  of  the  Formation  of  Ideas  and  Concepts         .        .      29 

Disturbances  of  the  Train  of  Thought 30 

External  association  of  ideas,  internal  association  of  ideas, 
paralysis  of  thought,  retardation  of  thought,  compulsive 
ideas,  simple  persistent  ideas,  perseveration,  stereotypy,  cir- 
cumstantiality, flight  of  ideas,  rambling  thought,  desultori- 
ness. 

Disturbances  of  Imagination 43 

Simple  sluggishness,  retardation,  indifference,  excitation  of 
the  imagination,  heightened  suggestibility,  autosuggesti- 
bility. 

Disturbances  of  Judgment  and  Reasoning 47 

Knowledge  and  belief,  delusions,  systematized  delusions,  delu- 


x  CONTENTS 

PAGE 

sions  of  self-depreciation,  delusions  of  poverty,  nihilistic 
delusions,  delusions  of  persecution,  delusions  of  jealousy, 
hypochondriacal  delusions,  delusions  of  self-aggrandize- 
ment, delusions  of  mental  soundness  (absence  of  insight), 
expansive  delusions. 

Disturbances  of  the  Rapidity  of  Thought 56 

Retardation,  acceleration. 
Disturbances  of  Capacity  for  Mental  Work  ....       57 

Disturbances  of  Self-consciousness 58 

Dual  personality,  double  consciousness,  falsifications  of  self- 
consciousness. 

C.  Disturbances  of  the  Emotions 62 

Diminution  and  Increase  of  Emotional  Irritability      ...       62 
Emotional   deterioration,   temporary   increase  of    emotional 
irritability,  change  of  mood. 

Morbid  Temperaments 65 

Increased  susceptibility  to  the  unpleasant,  apprehensiveness, 
irritable  dispositions,  seclusiveness,  sunny  dispositions, 
fanaticism,  morbid  frivolity. 

Morbid  Emotions 68 

Fear,  compulsive  fears,  phobias,  dejection,  sadness  with  ex- 
citement, morbid  feeling  of  pleasure,  wanton  happiness, 
drunkards'  humor,  feeling  of  well-being. 

Disturbances  of  General  Feelings 73 

Ennui,  fatigue,  hunger,  nausea,  pain,  feeling  of  shame,  sexual 
indifference,  increase  of  the  sexual  excitability,  perverted 
sexual  feelings. 

D.  Disturbance  of  Volition  and  Action 77 

Diminution  of  Volitional  Impulses 77 

Paralysis  of  the  will. 
Increase  of  Volitional  Impulse 78 

Motor  excitement,  pressure  of  activity,  busyness. 
Impeded  Release  of  the  Volitional  Impulse  ....       79 

Psychomotor  retardation,  stupor,  blocking  of  the  will,  rigid 
tension. 
Facilitated  Release  of  Volitional  Impulses 81 

Distractibility  of  the  will. 
Heightened  Susceptibility  of  the  Will 83 

Weakness  of  will,  hypersuggestibility,  catalepsy,  cerea  flexi- 
bilitas,  echopraxia,  echolalia,  distractibility  of  the  will. 
Interference  and  Stereotypy 84 

Crossing  of  voluntary  impulses,  stereotypy,  mannerisms,  su- 
perfluous embellishment,  derailment  of  will. 


CONTENTS  xi 


PAGE 


Diminished  Susceptibility  of  the  Will 88 

Negativism,  mutism. 

Compulsive  Acts 90 

Impulsive  Acts 90 

Morbid  Impulses 91 

Contrary  sexual  instincts,  sadism,  masochism,  fetichism,  klep- 
tomania, pyromania. 

Disturbances  of  Expression 93 

Conduct  arising  from  a  Morbid  Basis 95 

Methods  of  Examination 97 

Family  history,  personal  history,  anamnesis  of  the  disease, 
status  praesens,  disturbances  of  perception,  clouding  of  con- 
sciousness, disturbances  of  apprehension,  disturbances  of 
attention,  disturbances  of  memory,  orientation,  train  of 
thought,  judgment,  emotional  field,  volitional  field. 

FORMS  OF  MENTAL  DISEASES 

Classification  of  Mental  Diseases 115 

Consideration  of  the  Factors  entering  into  a  Provisional  Classi- 
fication     115 

I.     Infection  Psychoses 121 

A.  Fever  Delirium 121 

Etiology.  Pathological  anatomy.  Symptomatology. 
Course.     Prognosis.     Treatment. 

B.  Infection  Deliria 125 

Initial  deliria  of  typhoid,  of  smallpox.  Infection 
delirium  of  malaria.  Delirium  of  chorea.  Deliria 
of  influenza,  hydrophobia,  and  septic  states.  Acute 
delirium. 

C.  Post-infection  Psychoses 131 

Mild   Form.     Second  group.     Severe  form.     Cerebro- 
pathia  psychica  toxamica. 
II.    Exhaustion  Psychoses 136 

A.  Collapse  Delirium 137 

Etiology.  Pathological  anatomy.  Symptomatology. 
Course.     Diagnosis.     Prognosis.     Treatment. 

B.  Acute  Confusional  Insanity  (Amentia)      ....     141 

Etiology.  Symptomatology.  Course.  Diagnosis. 
Prognosis.     Treatment. 

C.  Acquired  Neurasthenia  (Chronic  Nervous  Exhaustion)     .     146 

Etiology.  Symptomatology.  Physical  symptoms. 
Course.     Diagnosis.     Prognosis.     Treatment. 


xii  CONTENTS 

PAGE 

III.  Intoxication  Psychoses 159 

1.  Acute  Intoxications 159 

Ptomaines.       Chloroform.       Santonin.       Hasheesh. 
Encephalopathia.      Saturninia. 

2.  Chronic  Intoxication 162 

A.  Alcoholism 162 

Acute  Alcoholic  Intoxication:  pathological  and 
anatomical  findings 162 

Chronic  Alcoholism  :  etiology,  pathological  anat- 
omy, symptomatology,  prognosis,  diagnosis, 
treatment 165 

Delirium  Tremens :  etiology,  pathological  anat- 
omy, symptomatology,  diagnosis,  prognosis, 
treatment    ........     172 

Korssakow's  Psychosis :  etiology,  pathological 
anatomy,  symptomatology,  course,  diagnosis, 
treatment    ........     183 

Acute  Alcoholic  Hallucinosis  :  etiology,  symptoma- 
tology, course,  diagnosis,  prognosis,  treatment     189 

Alcoholic  Hallucinatory  Dementia:  symptoma- 
tology, course,  diagnosis 195 

Alcoholic  Paranoia :  symptomatology,  course, 
diagnosis,  treatment 197 

Alcoholic  Paresis 200 

Alcoholic  Pseudoparesis 201 

B.  Morphinism 202 

Etiology.  Pathological  Anatomy.  Acute  Mor- 
phine Intoxication.  Chronic  Intoxication. 
Abstinence  Symptoms.  Course.  Diagnosis. 
Prognosis.      Treatment. 

C.  Cocainism 209 

Etiology.  Acute  Cocain  Intoxication.  Chronic 
Cocain  Intoxication.  Cocain  Hallucinosis. 
Prognosis.      Treatment. 

IV.  Thyroigenous  Psychoses 214 

A.  Myxcedematous  Insanity 214 

Etiology.     Symptomatology.     Course.     Treatment. 

B.  Cretinism 216 

Etiology.     Pathological  Anatomy.    Symptomatology. 
Treatment. 

V.     Dementia  Prsecox 219 

Etiology 219 

Pathology 221 


CONTENTS  xiii 

PAGK 

General  Symptomatology :  disturbances  of  apprehension, 
disturbances  of  orientation,  hallucinations,  disturbance 
of  consciousness,  disturbance  of  attention,  disturbance 
of  memory,  disturbance  of  the  train  of  thought,  dis- 
turbance of  judgment,  disturbance  of  the  emotional 
field,  disturbances  in  the  volitional  field        .         .         .     222 

Physical  Symptoms 229 

Hebephrenic  Form :    symptomatology,  physical  symptoms, 

course 230 

Catatonic   Form:    pathological   anatomy,   symptomatology, 

physical  symptoms,  course 241 

Paranoid  Forms : 

Dementia  Paranoides:  symptomatology,  physical  symp- 
toms, course 257 

Second  Group :  symptomatology,  course      ....    260 

Diagnosis  of  Dementia  Prsecox 265 

Treatment  of  Dementia  Praecox 272 

VI.     Dementia  Paralytica 276 

Etiology  (juvenile  paresis) 276 

Pathology 279 

Pathological  Anatomy 280 

General  Symptomatology:  disturbances  of  apprehension, 
disturbances  of  memory,  disturbances  of  the  train  of 
thought,  disturbances  of  judgment,  disturbances  of  the 

emotions,  conduct 285 

Physical  Symptoms :  sensory  symptoms,  paralytic  attacks, 
disturbances  of  speech,  ataxia,  reflexes,  vasomotor  dis- 
turbances          ...    290 

Demented  Form 299 

Expansive  Form  (megalomania)     ..         =        ...     301 

Agitated  Form  (galloping  paresis) 307 

Depressed  Form 310 

Course  of  Dementia  Paralytica 314 

Diagnosis  of  Dementia  Paralytica 315 

Prognosis  (arrested  paresis) 318 

Treatment •        .         •     319 

VII.     Organic  Dementias °    323 

Gliosis  of  Cortex  (diffused  cerebral  sclerosis)      .         .         .     323 
Huntingdon's  Chorea:  physical  symptoms,  course,  diag- 
nosis, pathological  anatomy 323 

Multiple  Sclerosis 326 

Cerebral  Syphilis:  simple  syphilitic  dementia,  syphilitic 
pseudoparesis 326 


xiv  CONTENTS 

PAS! 

Tabetic  Psychoses 332 

Arteriosclerotic  Insanity :  pathological  anatomy,  symp- 
tomatology, severe  progressive  form,  diagnosis,  treatment    333 

Cerebral  Tumor 341 

Brain  Abscess 343 

Cerebral  Apoplexy 343 

Cerebral  Trauma :  traumatic  delirium,  traumatic  dementia     344 
VIII.     Involution  Psychoses 348 

A.  Melancholia 348 

Etiology.  Pathological  anatomy.  Symptomatology : 
delusions  of  self-accusation,  hypochondriacal  delu- 
sions, hallucinations,  disturbances  of  thought, 
nihilistic  delusions.  Physical  symptoms.  Course. 
Diagnosis.     Prognosis.     Treatment. 

B.  Presenile  Delusional  Insanity 364 

Etiology.  Symptomatology.  Diagnosis.  Prog- 
nosis.    Treatment. 

C.  Senile  Dementia 369 

Etiology.  Pathological  anatomy.  Symptomatology. 
Physical  symptoms.  Severer  grade  of  senile  de- 
mentia. Presbyophrenia.  Senile  Delirium.  Se- 
nile Delusional  Insanity.     Diagnosis.     Treatment. 

IX.     Manic-depressive  Insanity 381 

Etiology 381 

Symptomatology :  disturbances  of  apprehension,  disturb- 
ances of  perception,  disturbances  of  memory,  disturb- 
ances of  judgment,  disturbances  of  thought,  disturbances 
of  the  emotional  and  volitional  fields       ....     382 

Manic  States 390 

Hypomania:  symptomatology,  physical  symptoms,  course      390 
Mania  (Tobsucht)  :  symptomatology,  physical  symptoms, 

course 394 

Delirious   Mania:    symptomatology,   physical    symptoms, 

course 397 

Depressive  States 400 

Simple  Retardation  :  symptomatology,  course     .         .         .     400 

Delusional  Form :  symptomatology 402 

Stuporous  States :  physical  symptoms,  course      .         .         .     405 

Mixed  States 407 

Irascible  mania.  Depressive  excitement.  Unproductive 
mania.  Manic  stupor.  Depression  with  a  flight  of  ideas. 
Depressive  state  with  flight  of  ideas  and  emotional  ela- 
tion. 


CONTEXTS  xv 

PAGE 

Course    of    Manic-depressive    Insanity :     duration,    lucid 
intervals,  transition  states 412 

Diagnosis 415 

Prognosis      ..........     417 

Treatment 419 

X.     Paranoia 423 

Etiology.     Symptomatology.     Course.     Diagnosis.     Prog- 
nosis.    Treatment. 

Querulent  Insanity 432 

XI.     Epileptic  Insanity 434 

Etiology.  Pathology.  Symptomatology.  Physical  symp- 
toms. Periodical  ill-humor.  Befogged  states :  pre- 
epileptic insanity,  post-epileptic  insanity,  psychic 
epilepsy,  somnambulism,  epileptic  stupor,  anxious 
deliria,  conscious  delirium,  dipsomania.  Diagnosis. 
Prognosis.  Treatment. 
XII.     The  Psychogenic  Neuroses 457 

A.  Hysterical  Insanity 457 

Etiology.  Pathology.  Symptomatology :  hysteri- 
cal personality,  changes  in  character,  hypochon- 
driasis. Physical  symptoms.  Befogged  states  : 
delirious  states,  hysterical  lethargy,  somnambu- 
lism, silly  excitement.  Course.  Diagnosis.  Prog- 
nosis.    Treatment. 

B.  Traumatic  Neurosis  (traumatic  hysteria)     .         .         .     475 

Etiology.  Symptomatology.  Diagnosis.  Prognosis. 
Treatment. 

C.  Dread  Neurosis 480 

Symptomatology.     Course.     Diagnosis.     Treatment. 
Xin.     Constitutional  Psychopathic  States.      (Insanity  of   Degen- 
eracy.)      485 

A.  Nervousness 485 

Symptomatology.     Course.     Diagnosis.     Treatment. 

B.  Constitutional  Despondency  ......     492 

Symptomatology.     Course.     Treatment. 

C.  Constitutional  Excitement     ......     495 

Symptomatology.     Diagnosis.     Treatment. 

D.  CompuLsive  Insanity      .......     498 

Tormenting  Ideas :  onomatomania,  arithmomania, 
Grubelsucht,  folie  du  doute,  erythrophobia.  Pho- 
bias :  agoraphobia,  mysophobia,  delire  du  toucher. 
Crises.  Impulsions.  Course.  Prognosis.  Treatment. 


xvi  CONTENTS 

PACK 

E.  Impulsive  Insanity 507 

The  impulse  to  tramp.  Pyromania.  Kleptomania. 
Impulse  to  kill.     Course.     Diagnosis.     Treatment. 

F.  Contrary  Sexual  Instincts 510 

Etiology.    Symptomatology.     Diagnosis.     Prognosis. 
Treatment. 
XIV.     Psychopathic  Personalities 515 

A.  Born  criminals  (moral  insanity,  "  delinquente  nato," 

moral  imbecility).      Etiology.      Symptomatology. 
Diagnosis.     Treatment 515 

B.  The  Unstable 521 

Symptomatology.     Diagnosis.     Treatment. 

C.  The  Morbid  Liar  and  Swindler 526 

Symptomatology.     Prognosis.     Treatment. 

D.  The  Pseudoquerulants 531 

Diagnosis.     Treatment. 
XV.     Defective  Mental  Development 536 

A.  Imbecility :  stupid  form,  lighter  grades,  energetic  type. 

Course.     Diagnosis.     Treatment     ....     536 

B.  Idiocy 544 

Etiology.  Pathology.  Symptomatology:  severe 
cases,  light  cases.  Diagnosis.  Prognosis.  Treat- 
ment. 


ILLUSTRATIONS 

FACING   PAGE 

Plate  1.    Muscular  tension  in  catatonic  stupor 246 

Plate  2.    Muscular  tension  in  catatonic  stupor    ......  248 

Plate  3.     Cerea  flexibilitas  in  catatonic  stupor 250 

Fig.  1.     Catatonic  writing  showing  verbigeration     ....  251 

Plate  4.     Illustrates  the  normal  pyramidal  cell  of  the  cerebral  cortex 

and  the  cytological  changes  occurring  in  dementia  paralytica         .  282 

Plate  5.  The  normal  cerebral  cortex ;  cerebral  cortex  in  idiocy  and 
dementia  paralytica ;  also  the  glia  in  the  normal  cortex,  the  pres- 
ence of  spider  cells  in  dementia  paralytica  and  their  relation  with 

the  blood-vessels 284 

Plate  6.     A  group  of  paretics,  illustrating  the  lack  of  expression  in 

the  countenance  and  the  inelastic  attitude 294 

Plate  7.     Paretic  handwriting 296 

Fig.  1.     Paretic  handwriting 296 

Fig.  2.     Paretic  handwriting  showing  partial  agraphia     .         .         .  296 

Fig.  3.     Paretic  handwriting  showing  complete  agraphia .         .         .  296 

Plate  8.     Paretic  handwriting 298 

Plate  9.     Group  of  three  cases  of  Huntingdon's  chorea,  all  of  whom 

were  trying  to  look  at  the  photographer  ......  324 

Plate  10.     Arteriosclerotic  cortex ;  normal  cortex       ....  334 

Plate  11.     Self-decorated  manic  patient 396 

Plate  12 398 

Fig.  1.    Macrocephaly 398 

Fig.  2.    Microcephaly 398 

Fig.  3.     Representing  asymmetry  of  cranium  and  face  398 

Fig.  4.    Representing  asymmetry  of  cranium  and  face      .        .        .  398 

xvii 


GENERAL   SYMPTOMATOLOGY 


GENERAL   SYMPTOMATOLOGY 


A.    DISTURBANCES   OF   THE   PROCESS   OF 
PERCEPTION 

The  perception  of  external  sensory  stimuli  depends 
upon  two  conditions:  the  adequate  stimulation  of  the 
sensory  end  organ ;  and  the  elaboration  of  this  stimulation 
by  the  central  nervous  system. 

The  loss  of  one  or  more  of  the  senses  modifies  mental 
development  in  proportion  to  the  importance  of  the  sen- 
sory material  lost  and  the  possibility  of  substituting  other 
sensory  experience.  Loss  of  sight  is  relatively  unimpor- 
tant, but  loss  of  hearing,  on  account  of  its  relation  to 
language,  is  of  great  importance ;  indeed,  unless  specially 
trained,  deaf  mutes  remain  mentally  weak  through  life. 

Illusions  and  Hallucinations. — More  important  than  the 
mere  absence  of  sensory  experience  is  its  falsification. 

Inadequate  stimulation  of  the  sense  organ  produces 
impressions  corresponding  to  the  "specific  energy"  of 
that  sense ;  for  instance,  an  electric  current  may  produce 
a  sound,  a  taste,  a  tactual  or  a  visual  sensation,  according 
as  it  stimulates  the  corresponding  sense  organ.  Such  sen- 
sations are  real  illusions,  but  they  do  no  harm  because 
they  are  immediately  recognized  as  illusions.  In  condi- 
tions of  mental  disturbance,  on  the  contrary,  especially 
where  there  is  great  clouding  of  consciousness,  the  sub- 
jective sensations  of  light  as  the  result  of  congestion  of 


4  GENERAL  SYMPTOMATOLOGY 

the  eye,  or  a  roaring  in  the  ear,  may  be  interpreted  as 
fire  or  torrents  of  water,  giving  rise  to  genuine  deceptions 
which  are  not  corrected.  This  sort  of  peripherally  con- 
ditioned sense  deception  has  been  called  elementary,  on 
account  of  its  origin  in  that  part  of  the  sensory  apparatus 
which  receives  the  stimulus. 

States  of  consciousness  similar  to  sensory  perceptions 
may  be  produced  by  the  excitation  of  the  so-called  cortical 
sensory  areas.  This  is  naturally  referred  to  an  external 
object,  and  results  in  an  illusion  as  to  the  real  source 
of  the  stimulus.  This  group  of  hallucinations  may  be 
called  perception  phantasms.  They  may  occur  in  normal 
individuals,  particularly  at  the  onset  of  sleep,  as  hypno- 
gogic  hallucinations.  In  abnormal  conditions,  they  are 
often  extremely  vivid  and  misleading.  They  usually 
bear  no  relation  to  the  content  of  thought,  and,  conse- 
quently, seem  to  the  patient  to  belong  to  the  external 
world.  They  have  a  fairly  uniform  content,  subject  only 
to  slight  modification  (stable  hallucinations  of  Kahlbaum), 
and  consist  of  senseless  words,  noises,  figures,  and  the  like, 
which  are  repeated  over  and  over  again.  Because  of  their 
central  origin,  they  may  occur  after  destruction  both  of 
the  peripheral  sense  organ  and  the  afferent  nerve.  The 
cases  of  hemilateral  disturbance  of  the  field  of  vision,  in 
which  the  gaps  produced  by  the  disordered  perception  are 
filled  out  by  the  patient,  point  clearly  to  central  origin  in 
that  portion  of  the  cortex  which  has  to  do  with  visual 
perception.  There  are  some  cases  in  which  sense  decep- 
tions have  prevailed  in  the  normal  half  of  the  field  of 
vision,  where  the  cortex  in  both  occipital  lobes  has  been 
diseased.  Again,  coincident  with  the  rapid  development 
of  the  bilateral  cortical  blindness  there  has  been  observed 
sudden  development  of  active  perception  of  light. 


DISTURBANCES   OF  THE  PROCESS  OF  PERCEPTION       5 

Peripheral  influences  may  also  produce,  directly  or  in- 
directly, conditions  of  excitation  in  the  higher  portions  of 
the  sensory  tracts,  which  lead  to  sense  deceptions,  particu- 
larly if  the  general  irritability  of  these  parts  is  increased. 
In  morbid  conditions,  ordinary  organic  stimuli  suffice  to 
produce  such  falsification.  In  other  cases,  these  halluci- 
nations may  appear  if  attention  is  merely  directed  to  that 
sensory  field,  or  if  an  emotional  condition  temporarily 
increases  the  general  susceptibility  to  stimulation.  It 
disappears,  on  the  other  hand,  as  soon  as  the  patient 
becomes  quiet  or  directs  his  attention  elsewhere,  as  in 
conversation,  manual  or  mental  employment,  change 
of  environment,  etc.  Further  evidence  of  cooperation  of 
conditions  of  stimulation  in  the  sense  organ  is  found  in 
the  occasional  occurrence  of  one-sided  hallucinations,  the 
frequent  association  of  chronic  middle  ear  disease  with 
hallucinations  of  long  standing,  and  the  production  of 
hallucinations  of  sight  in  alcoholic  delirium  by  gentle 
pressure  on  the  eyeball.  Usually  these  sense  decep- 
tions appear  only  in  a  single  sensory  field,  and  are  most 
frequent  in  the  fields  of  hearing  and  sight. 

Sense  deceptions  are  divided  clinically  into  hallucina- 
tions and  illusions.  In  the  former  there  are  no  recog- 
nizable external  stimuli;  the  latter  are  falsifications  of 
real  percepts.  In  some  cases  this  distinction  may  be  dif- 
ficult to  carry  out  on  account  of  internal  stimulation  of 
the  sense  organs,  such  as  occurs  in  phosphenes,  entotic 
noises,  etc.  In  other  cases  the  distinction  is  clear.  The 
perception  of  ghosts  in  moving  clouds  and  limbs  of  trees, 
curses  and  threats  in  ringing  bells,  are  evidently  illusions. 
But  the  well-known  visual  disturbance  of  the  alcoholic, 
and  the  voices  which  torture  the  condemned  in  his  prison, 
when  everything  is  quiet,  are  pure  hallucinations. 


6  GENERAL  SYMPTOMATOLOGY 

The  universal  characteristic  of  the  entire  group  of  sense 
deceptions  is  their  sensory  vividness.  They  depend  on  the 
same  sort  of  cerebral  processes  as  does  normal  perception, 
and  the  false  perception  takes  its  place  in  consciousness 
among  the  normal  sensory  impressions  without  any  dis- 
tinguishing characteristic.  The  patients  do  not  merely 
believe  that  they  see,  hear,  and  feel,  but  they  really  see, 
hear,  and  feel. 

In  morbid  conditions  very  vivid  ideas  or  memory  images 
may  assume  the  form  of  hallucinations,  being  regarded  by 
the  patients  as  real  perceptions  of  a  peculiar  kind.  Many 
investigators  hold  that  all  false  perceptions  should  be 
regarded  as  ideas  of  imagination  of  extraordinary  sensory 
vividness.  But  in  order  that  an  idea  attain  the  clearness 
of  a  perception,  some  special  cause  must  be  present.  This 
is  indicated  by  the  fact  that  in  patients  suffering  from 
hallucinations,  not  all,  but  only  certain  groups  of  ideas 
seem  to  play  a  role  in  the  sense  deceptions,  and  besides  these 
there  are  usually  ideas  of  the  ordinary,  faded,  and  formless 
type.  The  element  which  makes  a  hallucination  out  of 
a  vivid  idea  is  probably  a  reflex  excitation  of  those  cen- 
tral sensory  tracts,  through  which  alone  normal  stimuli 
come  to  consciousness  (the  so-called  "reperception"  of 
Kahlbaum) .  If  it  is  really  these  areas  of  the  brain  through 
whose  excitation  perception  acquires  its  peculiar  sensory 
marks,  it  is  easy  to  see  how  they  may  participate  in  vary- 
ing degrees  in  the  active  process  of  renewing  previous  impres- 
sions. A  view  of  this  sort  would  explain  the  fact  that  there 
lies  between  the  sense  deception  of  pronounced  sensory  vivid- 
ness and  the  most  faded  memory  image  an  unbroken  series 
of  transition  stages.  It  is  possible  that  during  the  ordinary 
thought  processes  this  reflex  excitation  or  reperception  is 
always  present  in  a  very  slight  degree,  but  that  only  when 


DISTURBANCES  OF  THE  PROCESS   OF  PERCEPTION      7 

the  process  becomes  morbid,  or  the  sensory  areas  themselves 
are  in  a  condition  of  increased  excitability,  does  the  vividness 
of  the  memory  picture  approach  that  of  true  sense  percep- 
tion. Probably  there  is,  moreover,  a  definite  relation  be- 
tween the  strength  of  the  reperception  and  the  irritability 
of  the  sensory  areas ;  the  greater  their  irritability,  the  more 
easily  will  the  memory  images  attain  sensory  vividness,  the 
lighter  the  reflex  excitation  need  be  to  release  them,  and  the 
more  independent  they  are  of  the  current  of  thought.  The 
extreme  case  would  be  found  in  the  sense  deceptions  depend- 
ing upon  local  excitation,  which  seem  to  the  patient  to  be 
something  quite  foreign  and  external.  The  extreme  case 
in  the  other  direction  would  be  those  instances  which  are 
not  true  sense  deceptions  at  all,  but  merely  ideas  of  great 
sensory  vividness.  By  careful  investigation  it  is  often  pos- 
sible to  analyze  the  data  given  by  the  patient,  which  appar- 
ently indicated  hallucinations,  and  to  discover  that  the  pa- 
tient does  not  regard  the  impression  as  objectively  real,  but 
merely  differentiates  it  from  his  ordinary  ideas  on  account 
of  its  forceful  vividness.  In  these  cases  it  is  probable  that 
the  reperception  is  strongly  developed,  while  irritability  of 
special  sensory  tracts  is  not  increased.  This  seems  to  be 
borne  out  by  the  fact  that  this  group  of  hallucinations,  which 
has  been  variously  designated  as  psychic  hallucinations 
(Baillarger),  pseudohallucinations  (Hagen),  and  apprehen- 
sion hallucinations  (Kahlbaum),  involves  several  or  all  of 
the  sensory  fields,  and  that  it  always  stands  in  close  relation 
to  the  other  contents  of  consciousness ;  while  the  true  falsi- 
fications of  perception,  on  the  other  hand,  usually  belong  to 
a  single  sensory  tract,  and  are  independent  of  the  train  of 
thought. 

A  striking  illustration  of  this  type  of  hallucinations  is 
found  in  a  condition  called  "double  thought."    Immediately 


8  GENERAL   SYMPTOMATOLOGY 

upon  the  appearance  of  any  idea,  the  patient  has  another  dis- 
tinctly subsequent  idea  of  the  same  thing ;  i.e.  every  idea 
is  followed  by  a  distinct  sensoiy  after-image.  This  double 
thought  occurs  most  frequently  when  the  patients  are  read- 
ing, sometimes  when  writing,  and  occasionally,  also,  when 
linguistic  ideas  come  vividly  to  consciousness.  The  sensory 
after-image  disappears  if  the  words  are  actually  spoken. 
Other  hallucinations  of  hearing  universally  accompany  this 
condition. 

Apperceptive  illusions  are  those  in  which  subjective  ele- 
ments unite  with  the  objective  sensory  data,  giving  rise  to  a 
distorted  and  falsified  impression.  They  are  of  very  fre- 
quent occurrence  in  normal  life ;  prejudice,  expectation,  and 
the  emotions,  continually  influence  our  perceptions  even  in 
spite  of  our  earnest  effort  to  be  neutral.  Even  the  most  tran- 
quil scientific  observer  is  never  quite  certain  that  his  per- 
ceptions do  not  unconsciously  suit  themselves  to  the  views 
with  which  he  approaches  his  investigation ;  while  in  reading 
we  all  unconsciously  correct  the  errors  of  the  type-setter 
from  the  residua  of  our  experience.  In  mental  disturb- 
ances the  conditions  are  often  extraordinarily  favorable 
for  this  falsification  of  apprehension.  Marked  emotional 
excitement,  great  activity  of  the  imagination,  and  finally, 
the  inability  to  sift  and  correct  experience  by  reason,  —  all 
are  favorable  to  its  development.  Thus,  it  frequently  hap- 
pens that  the  sensory  impressions  of  patients  take  on  fan- 
tastic forms  and  become  the  basis  of  a  thoroughly  falsified 
apprehension  of  the  external  world,  even  when  there  are 
no  true  hallucinations.  This  phenomenon  naturally  occurs 
most  frequently,  both  in  normal  and  abnormal  states,  when 
the  sensory  impressions  are  confused  and  indefinite,  and  not 
readily  differentiated. 

There  is  an  allied  group  of  disturbances  which  consists 


DISTURBANCES  OF  THE  PROCESS  OF  PERCEPTION   9 

in  the  release  of  a  false  perception  in  one  sensory  field 
through  a  real  impression  received  by  another,  constitut- 
ing the  so-called  "reflex  hallucinations  of  Kahlbaum."  A 
sensory  stimulus  may  produce  conditions  of  excitation, 
which,  transferred  to  an  over-excited  sensory  area,  occasion 
the  development  of  an  hallucination.  Similar  conditions 
are  daily  encountered  in  the  so-called  sympathetic  sensa- 
tions, like  the  unpleasant  sensation  of  an  inexperienced  on- 
looker at  a  painful  surgical  operation.  In  morbid  condi- 
tions these  may  be  very  marked.  Especially  sensations  of 
movement  which  frequently  accompany  sense  impressions 
seem  to  rise  in  this  way.  There  are  patients  who  feel  on 
their  tongues  the  words  spoken  by  others;  a  glance  from 
some  one  may  excite  a  sensation  of  strain. 

A  very  important  characteristic  of  sense  deceptions, 
which  in  one  way  points  to  their  origin  and  in  another  to 
their  importance  as  a  disease  symptom,  is  the  powerful  and 
irresistible  influence  which  they  exert  over  the  entire  thought 
and  activity  of  the  patient.  It  is  true  that  occasionally  a 
pronounced  illusion  appears  in  persons  mentally  sound ;  and, 
also,  that  at  the  beginning,  as  well  as  at  the  end,  of  a  mental 
disease  the  illusions  are  often  recognized  as  such,  because  of 
their  improbable  content,  but  usually  persistent  illusions  and 
hallucinations  overpower  the  judgment,  and  ultimately  the 
patients  invent  the  most  foolish  and  fantastic  explanations 
to  account  for  them. 

The  basis  for  this  irresistible  influence  is  not  to  be  found 
in  the  sensory  vividness  of  the  illusion,  since  real  sensa- 
tions and  definite  evidence  are  useless  as  correctives.  Its 
explanation  is  found  rather  in  the  intimate  connection  be- 
tween the  illusions  and  the  patient's  innermost  thought,  morbid 
fears,  and  desires.  The  emotional  states  and  the  feelings 
color  the  illusions  in  a  peculiarly  high  degree,  as  one  might 


10  GENERAL  SYMPTOMATOLOGY 

expect  from  their  influence  in  normal  life.  It  is  frequently 
observed,  especially  in  the  end  stages  of  dementia  praecox, 
that  illusions  appear  only  in  connection  with  the  periodical 
vacillations  of  the  emotional  state,  while  they  completely 
disappear  in  the  interval.  This  influence  of  the  emotional 
life  upon  the  thought  and  actions  only  disappears  with  re- 
covery, or  when  progressive  deterioration  obliterates  emo- 
tional activity.  In  both  cases  the  illusions  may  continue, 
but  the  patients  do  not  react  upon  them. 

These  facts  manifestly  disprove  the  general  view  that 
sense  deceptions  regularly,  or  even  frequently,  act  as  the 
real  causes  of  delusions.  To  be  sure,  patients  point  to 
their  hallucinations  as  the  basis  of  their  symptoms,  but 
there  can  be  no  doubt  that  the  sense  deceptions  have  a 
common  source  of  origin  with  the  other  disturbances  of  the 
mental  equilibrium.  In  reality  the  patient's  attitude  toward 
his  illusions  and  hallucinations  is  not  the  same  as  his  atti- 
tude toward  his  actual  perceptions.  No  healthy  individual 
would  refer  to  himself  such  words  as  "That  is  the  president," 
and  then  immediately  believe  he  must  be  the  president. 
But  when  these  words  form  the  keystone  of  a  long  chain  of 
secret  misgivings,  an  hallucination  of  that  sort  makes  the 
most  profound  impression,  and  immediately  there  arises  a 
firm  conviction,  not  only  that  the  words  were  really  spoken, 
but  that  they  express  the  truth. 

In  view  of  these  facts  we  see  no  special  practical  value 
in  distinguishing  in  single  cases  whether  the  delusion,  the 
emotional  state,  or  the  corresponding  sense  deceptions 
appear  first.  In  the  vast  majority  of  cases,  and  especially 
where  the  sense  deceptions  appear  with  persistent  delu- 
sions, all  of  these  disease  symptoms  are  certainly  only  the 
result  of  one  and  the  same  common  cause. 

Illusions  and  hallucinations  present  a  large  number  of 


DISTURBANCES  OF  THE   PROCESS  OF  PERCEPTION    11 

clinical  types  in  the  different  sensory  fields.  The  most  fre- 
quent sense  deceptions  of  sight  are  those  which  occur  at 
night,  the  so-called  visions;  God,  angels,  dead  persons, 
distorted  figures,  wild  animals,  and  the  like.  The  less 
common  sense  deceptions  of  sight  which  appear  in  day- 
light along  with  the  normal  impressions  are  much  more  like 
normal  perceptions  and  consequently  more  deceptive.  The 
sense  deceptions  of  the  alcoholics  are  of  this  type  (see 
p.  176).  The  objects  of  the  surroundings  may  take  on  an 
entirely  different  appearance;  patients  mistake  strangers 
for  relatives  and  vice  versa,  and  believe  that  the  same 
persons  are  taking  on  different  forms  and  faces,  are  making 
grimaces,  etc. 

The  most  important  sense  deceptions  of  hearing  are  the 
so-called  voices,  a  term  which  is  usually  well  understood  by 
the  patient.  The  basis  for  their  importance  lies  in  the  funda- 
mental significance  of  language  in  our  psychic  fife.  The 
voices  usually  have  an  intimate  relation  to  the  content  of 
consciousness;  in  fact,  they  are  the  linguistic  expressions 
of  the  patient's  inmost  thought,  and  for  this  reason  have 
for  him  a  far  greater  convincing  power  than  all  other  sense 
deceptions,  more  even  than  real  speech.  The  voices  mock 
the  patient,  threaten  him,  and  tell  his  secrets.  They  are 
heard  in  the  scratching  of  a  pen,  in  the  barking  of  dogs,  etc. 
Sometimes  there  are  several  distinct  " voices"  with  char- 
acteristic differences.  Usually  they  are  low,  as  if  coming 
from  a  distance,  though  occasionally  they  are  loud  enough  to 
drown  all  other  noises.  It  rarely  happens  that  the  "  voices  " 
speak  long  sentences.  Usually  they  consist  of  short,  in- 
terrupted remarks.  The  hallucinations  in  fever  delirium 
and  in  greatly  bewildered  patients  are  changeable  and  con- 
fused. 

Auditory  sense  deceptions  are  seldom  indifferent  to  the 


12  GENERAL   SYMPTOMATOLOGY 

patients,  but  are  almost  always  accompanied  by  strong 
emotional  disturbances  and  wield  a  powerful  influence  over 
the  patients'  actions.  They  make  them  distrustful,  excited, 
and  even  drive  them  to  angry  attacks  on  their  imaginary 
tormentors. 

The  so-called  "internal  voices,"  "suggestions,"  "tele- 
phoning," "telegraphing,"  etc.,  form  a  special  group  of 
hallucinations  of  hearing.  These  naturally  are  not  regarded 
by  the  patients  as  sensory  in  their  origin.  They  may  occur 
as  a  kind  of  monologue  or  as  a  conversation  with  distant 
persons;  sometimes  the  voices  of  conscience  seem  to  criti- 
cise the  patient  or  spur  him  on.  In  all  these  cases  the  pa- 
tient develops  the  delusion  that  his  thoughts  are  known  to 
even-  one,  or  that  they  are  produced  and  influenced  by  out- 
side forces. 

Sense  deceptions  in  the  other  senses  are  of  much  less 
importance.  False  perceptions  of  taste,  smell,  dermal, 
muscular,  and  general  senses,  so  far  as  they  derive  their 
origin  from  the  thoughts  of  the  patient,  and  not  from  the 
disturbance  of  the  sense  organs,  point  to  a  profound  change 
of  the  whole  psychical  personality. 

^Where  delusions  of  electrical  influence,  of  position,  of 
incasement  of  different  organs  of  the  body,  the  disappear- 
ance of  the  ears,  mouth,  etc.,  are  present  we  no  longer  have 
simple  illusions  and  hallucinations,  but  almost  always  a 
severe  disturbance  of  the  higher  psychical  processes. 

Hallucinations  develop  differently.  One  might  judge 
this  from  their  great  variety.  The  type  of  the  hallucination 
may  be  determined  in  a  measure  by  the  form  of  the  mental 
disease.  In  fever  delirium  and  infection  psychoses  the 
hallucinations  and  illusions  are  variable  and  dreamlike,  oc- 
curring in  all  the  different  fields  of  sensation  and  producing 
a  most  confused  and  fantastic  experience.     Similar  hallu- 


DISTURBANCES  OF  THE   PROCESS   OF  PERCEPTION    13 

cinations  and  illusions  exist  in  the  alcoholic  delirium,  but 
here  they  present  a  peculiar  sensory  vividness  and  they  com- 
bine so  that  the  separate  experiences  are  much  more  defi- 
nite. Indeed,  they  combine  so  intimately  with  each  other 
that  they  offer  a  good  foundation  for  the  development  of 
an  "occupation  delirium."  Another  characteristic  of  these 
alcoholic  hallucinations  and  illusions  is  that  they  are  very 
numerous  and  change  rapidly.  These  sense  deceptions, 
originating  as  they  do  from  imperfectly  perceived  impres- 
sions, can  even  be  created  and  influenced  by  mere  suggestion. 
The  hallucinations  in  cocainism  which  appear  in  the  visual 
and  auditory  fields  and  in  the  field  of  general  sensibility 
are  closely  related.  The  " microscopic"  hallucinations  of 
sight  are  particularly  characteristic;  i.e.  the  perception  of 
numerous  minute  objects,  little  animals,  or  holes  in  the  wall 
or  little  points.  On  the  other  hand  in  the  epileptic  delirium 
the  hallucinations  are  accompanied  by  a  peculiarly  intense 
tone  of  feeling;  for  instance,  the  sight  of  blood,  of  fire, 
objects  of  fear,  the  hearing  of  threats,  the  noise  of  shooting, 
or  the  music  of  angels.  In  all  of  these  conditions  it  is 
probable  that  there  is  an  extensive  involvement  of  the  cor- 
tex by  the  disease  process.  This  seems  the  more  probable 
as  clouding  of  consciousness  regularly  accompanies  these 
states.  Other  disease  processes  present  even  more  transi- 
tory delirious  states  with  hallucinations  involving  the  dif- 
ferent senses:  such  as  manic-depressive  insanity,  senile 
dementia,  dementia  prsecox,  and  occasionally  paresis.  In 
the  bewildered  and  excited  stages  of  dementia  prsecox  hal- 
lucinations of  hearing  predominate,  while  in  similar  states 
in  manic-depressive  insanity  hallucinations  of  sight  are 
more  prominent,  and  particularly  hallucinations  of  the  gen- 
eral sensibility.  In  paresis  illusions  are  much  more  evident 
than  hallucinations,  although  both  are  comparatively  infre- 


14  GENERAL  SYMPTOMATOLOGY 

quent.  There  is  only  a  small  group  of  cases  in  which  the 
sense  deceptions  involve  only  a  single  sensation ;  as,  for  in- 
stance, in  most  cases  of  acute  alcoholic  hallucinosis,  and 
some  cases  of  alcoholic  hallucinatory  dementia,  in  which 
there  are  very  striking  hallucinations  of  hearing.  Also  in 
some  epileptic  states,  hallucinations  of  hearing  only  appear. 
Hallucinations  of  hearing  alone  are  by  far  most  frequent  in 
dementia  praecox.  They  are  rarely  absent  long.  Usually 
they  represent  one  of  the  first  symptoms  and  often  they  con- 
tinue as  the  only  symptom  for  some  time.  In  the  delirious 
states  of  dementia  praecox  they  are  usually  associated  with 
hallucinations  and  illusions  of  the  other  senses.  It  is  also  in 
dementia  praecox  that  the  peculiar  disturbance  called 
"double  thought"  mostly  occurs.  The  content  of  the  hal- 
lucinations is  of  a  fearful  or  disturbing  nature  only  at  the 
beginning,  while  later  it  becomes  more  or  less  indifferent  and 
senseless,  which  is  in  marked  contrast  to  the  other  forms  of 
mental  diseases  mentioned  above. 

Clouding  of  Consciousness.  —  External  stimuli  occasion 
within  us  characteristic  mental  phenomena  which  we  appre- 
hend immediately  and  distinguish  as  presentations,  feel- 
ings, and  volitions.  This  experience  is  designated  as  con- 
sciousness, which  is  present  whenever  physiological  stimuli 
are  converted  into  psychic  processes.  The  nature  of  con- 
sciousness is  obscure,  yet  we  know  not  only  that  it  in  gen- 
eral depends  upon  the  functioning  of  the  cerebral  cortex, 
but  also  that  its  individual  phenomena  are  connected  with 
definite,  but  as  yet  undetermined,  physiological  processes 
in  the  nervous  system.  Just  as  the  transition  of  the  external 
stimuli  into  sensory  excitations  depends  upon  the  nature  of 
the  sensory  organ,  so  the  condition  of  the  cerebral  cortex 
is  the  determining  factor  in  the  transformation  of  physiologi- 
cal into  conscious  processes.     Whether  such  transformation 


DISTURBANCES  OF  THE  PROCESS  OF  PERCEPTION    15 

takes  place  in  individual  cases  is  often  very  difficult  to  deter- 
mine, since  we  have  no  immediate  insight  into  the  inner 
experience  of  others  and  are  compelled  to  draw  our  conclu- 
sions from  their  behavior. 

The  condition  in  which  the  transformation  of  physio- 
logical into  psychical  processes  is  completely  suspended,  is 
designated  unconsciousness.  Every  stimulus  which  crosses 
the  threshold  of  consciousness,  thereby  arousing  a  psychic 
process,  must  possess  a  certain  intensity  which  cannot  sink 
below  a  definite  limit.  This  limit  is  called  the  threshold 
value  and  varies  greatly  according  to  the  condition  of  the 
cortex.  While  it  is  lowest  in  strained  attention,  the  thresh- 
old value  reaches  infinity  in  the  deepest  coma.  It  is  thus 
possible  to  distinguish  different  degrees  of  the  clearness  of 
consciousness  according  to  the  character  of  the  threshold 
value.  But  even  when  conscious  processes  are  no  longer 
aroused  by  external  stimuli,  consciousness  in  the  form 
of  obscure  presentations  and  general  feelings  may  still 
exist. 

If  the  clearness  of  consciousness  decreases  sufficiently, 
befogged  consciousness  results  (Ddmmerzustand) ,  during 
which  neither  the  external  nor  internal  stimuli  can  create 
clear  and  distinct  presentations.  These  befogged  states  are 
encountered  in  epileptic  and  hysterical  insanities,  as  transi- 
tory states  contrasting  sharply  with  the  normal  life  of  the 
individual.  Prolonged  befogged  states  are  also  found  in 
which  mental  processes  are  rendered  difficult  and  the 
psychophysical  threshold  is  considerably  raised.  Some- 
times the  threshold  value  may  be  so  altered  that  it  is  dif- 
ferent for  external  and  internal  stimuli  ;  that  is,  while 
external  stimuli  have  little  effect,  internal  stimuli  produce 
vivid  conscious  processes.  This  is  what  occurs  in  delirious 
states.    The  opposite  condition  obtains  in  demented  states, 


16  GENERAL  SYMPTOMATOLOGY 

where  not  infrequently  external  stimuli  easily  produce  sen- 
sations, while  internal  have  little  effect  in  consciousness. 
What  occurs  here  is  not  an  increase  of  the  threshold  value, 
but  a  prolonged  sinking  of  the  psychophysical  excitation. 
Indeed,  this  is  the  distinction  between  dementia  and  the 
befogged  states. 

Disturbance  of  Apprehension.  —  The  full  effect  of  an 
external  stimulus  takes  time.  Experiment  demonstrates 
that  our  sense  perceptions  reach  the  point  of  greatest  clear- 
ness only  after  a  period  of  some  seconds.  Under  some 
circumstances  this  process  may  be  retarded.  Stimuli  of 
short  duration  are  either  not  apprehended  at  all,  or  only 
incompletely,  although  no  real  difficulty  of  apprehension 
is  present.  If  the  retardation  in  the  development  of 
sensory  impressions  is  considerable,  the  impressions  fade 
away  before  they  are  really  perceived.  Some  very  strong 
impressions  may  be  apprehended,  but  they  are  more  or 
less  incoherent  because  the  connecting  links  and  the 
accompanying  events  reach  consciousness  only  in  an  in- 
coherent and  confused  form.  This  disturbance  of  appre- 
hension in  its  pronounced  form  is  encountered  in  senile 
dementia  (presbyophrenia)  and  Korrsakow's  psychosis,  but 
exists  in  a  much  less  marked  degree  in  many  other 
psychoses,  particularly  of  the  delirious  type. 

The  apprehension  of  external  impression  requires  not 
only  the  development  of  a  percept  of  sufficient  strength, 
but  also  its  absorption  into  the  systematic  interconnections 
of  our  experience.  The  vast  majority  of  our  impressions 
at  any  given  moment  are  obscure  and  confused.  Presen- 
tations only  become  clear  and  distinct  when  they  find  residua 
of  past  experience  in  the  memory,  "resonators,"  as  it  were, 
through  whose  sympathetic  vibration  the  sensory  stimu- 
lation is  intensified.     It  is  through  this  process,   which 


DISTURBANCES  OF  THE  PROCESS  OF  PERCEPTION    17 

Wundt  calls  " apperception,"  that  each  percept  becomes 
united  with  our  past  experience,  through  which  alone  it  can 
be  understood.  This  supplementing  the  given  impression 
by  memory  images  greatly  increases  the  delicacy  of  our 
apprehension,  but  brings  with  it  the  danger  of  a  falsification 
of  perception. 

The  most  frequent  type  of  the  disturbance  of  appre- 
hension is  the  increase  of  the  threshold  value  for  external 
stimuli.  The  more  intense  the  stimuli  must  be  in  order  to 
produce  an  impression,  the  more  confused  and  defective 
will  be  the  picture  of  the  external  world.  The  patients 
apprehend  only  a  small  part  of  the  impressions  which 
they  receive.  They  fail  to  note  and  to  understand  their 
environment.  We  call  this  diminished  sensibility.  The 
gradual  development  of  this  disturbance  of  apprehension 
is  found  in  simple  fatigue  and  its  transitions  into  sleep, 
but  also  in  the  morbid  states  of  extreme  mental  exhaus- 
tion. Ether  and  chloroform  isolate  our  consciousness  from 
the  external  world  most  completely  and  rapidly,  but  a 
number  of  narcotics  act  in  a  similar  way ;  such  as,  alco- 
hol, paraldehyde,  and  trional.  Diminished  sensibility  is  also 
found  in  fever,  and  intoxication  deleria,  as  well  as  in  the 
clouded  consciousness  of  epilepsy  and  hysteria.  Oftentimes 
it  is  also  found  in  the  various  phases  of  manic-depressive 
insanity,  especially  in  the  depressive  and  manic  stupor, 
but  also  in  the  more  intense  maniacal  excitement. 

The  entire  sensory  experience  in  the  first  stages  of  men- 
tal development  remains  on  the  plain  of  simple  perception. 
As  long  as  the  impressions  of  the  external  world  have  left 
no  memory  residue  there  is  no  network  of  psychological 
associations  through  which  new  experience  may  be  related 
to  the  past.  In  the  severest  forms  of  arrested  mental 
development  this  condition  persists,  and  there  is  no  possi- 


18  GENERAL  SYMPTOMATOLOGY 

bility  of  the  gradual  clearing  of  the  clouded  consciousness. 
It  remains  forever  a  confused  medley  of  vague  isolated 
presentations  and  feelings,  in  which  there  is  no  clear  appre- 
hension or  order. 

Disturbances  of  Attention.  —  At  any  one  moment  there 
is  present  in  our  inner  field  of  view  only  a  limited  number 
of  mental  phenomena.  This  limitation  of  consciousness 
is  called  the  "span  of  consciousness."  Since  the  entire 
chain  of  our  psychical  life  must  pass  under  the  limitations 
of  this  span,  our  inner  life  presents  a  constant  coming  and 
going  of  mental  processes.  One  experience  after  another 
appears  and  disappears ;  each  approaches  from  the  dark- 
ness of  the  unconscious,  at  first  being  indistinct  and  weak, 
after  a  short  time  reaching  the  climax  of  its  clearness  and 
strength,  and  then  sinking  from  sight  to  give  place  to 
another.  This  development  of  a  mental  phenomenon 
within  the  field  of  consciousness  is  coincident  with  that 
inner  activity  of  the  will  which  we  call  attention.  Our 
sense  organs  turn  to  the  forceful  impressions,  and  those 
presentations  appear  which  strengthen  the  process  that 
claims  our  attention.  The  strain  of  attention  may  have 
various  degrees  and  directions.  It  is  accompanied  by  cer- 
tain physical  phenomena  ;  such  as,  movements  of  the  body, 
alterations  in  breathing,  pulse,  and  blood  pressure. 

Attention  not  only  strengthens  a  developing  impression, 
but  without  doubt  it  retards  its  fading.  In  this  way  each 
impression  exerts  an  influence  on  its  successors.  Their  re- 
lation to  their  predecessor  inhibits  or  promotes  their  devel- 
opment. In  this  manner  the  primitive  passive  and  aimless 
attention  becomes  active  and  selective.  It  is  not  the  force 
of  the  external  impressions,  but  rather  the  attention,  which 
determines  our  inner  experience.  Experience  is  determined 
not  so  much  by  the  strength  of  external  impressions  as  by 


DISTURBANCES  OF  THE   PROCESS  OF  PERCEPTION     19 

the  favoring  or  inhibiting  effect  of  attention.  In  a  child 
the  content  of  consciousness  is  helplessly  dependent  upon 
accidental  circumstances ;  it  perceives  only  the  most  strik- 
ing stimuli.  In  adults,  on  the  other  hand,  the  process  of 
perception  is  more  and  more  dominated  by  personal  tenden- 
cies which  gradually  develop  out  of  the  experiences  of  the 
individual.  We  train  ourselves  to  notice  certain  impressions 
in  preference  to  others,  so  that  some  stimuli,  however  faint, 
have  decided  advantage  over  others.  On  the  other  hand, 
we  accustom  ourselves  to  be  inattentive  to  regularly  recur- 
ring stimuli,  yielding  them  no  influence  over  our  psychic 
processes.  This  development  of  definite  "points  of  view," 
definite  directions  of  interest,  leads  to  an  extraordinary 
variability  of  the  threshold  of  consciousness,  so  that  at  the 
same  moment  when  strong  stimuli  pass  quite  unnoticed,  we 
apprehend  with  greatest  acuteness  the  slightest  alterations 
in  some  special  object. 

The  attention  is  variously  affected  in  different  psychoses. 
In  the  first  place,  in  all  conditions  of  advancing  dementia 
there  is  a  blunting  of  attention.  Perceptions  arouse  no  cor- 
responding memory  images.  They  are  not  united  with  the 
patient's  past  experience  and  they  fail  to  incite  him  to 
pursue  them  further  on  his  own  initiative.  In  the  case  of  a 
deteriorated  paretic  the  most  striking  occurrences  may  take 
place  without  creating  any  impression,  although  he  may  be 
able  to  comprehend  questions.  In  dementia  prsecox  a 
striking  disorder  of  the  attention  is  present  from  almost  the 
inception  of  the  disease.  Particularly  in  the  stuporous 
states,  all  attempts  to  arouse  the  attention  are  unsuccessful, 
even  prodding  with  a  needle,  or  touching  the  cornea,  fails 
to  create  any  voluntary  movement.  This  is  not  a  blunting 
of  the  attention  but  a  suppression  of  the  attention.  The 
patients  perceive  well  enough  what  takes  place  about  them, 


20  GENERAL  SYMPTOMATOLOGY 

but  they  involuntarily  prevent  the  perception  influencing 
their  thought  or  action.  Even  all  the  external  expressions 
that  accompany  attention,  such  as  the  turning  of  the  head 
and  eyes,  and  apparently  also  the  alteration  of  the  pulse 
and  breathing,  are  absent.  This  disorder  corresponds 
with  the  negativistic  processes  found  in  disturbances  of 
volition  and  may  be  called  a  blocking  (Sperrung)  of  the 
attention. 

In  some  stuporous  states  of  manic-depressive  insanity  a 
retardation  of  the  attention  occurs.  Here  also  it  is  difficult 
to  get  into  touch  with  the  patient,  but  only  because  he  lacks 
that  internal  process  which  connects  his  external  impressions 
and  his  past  experience,  and  incites  the  selective  activity 
of  the  attention.  The  development  of  ideas  is  rendered 
difficult,  not  on  account  of  deterioration  in  the  mental  life, 
but  through  the  process  of  retardation  which  prevents  the 
perceptions  from  gaining  any  extensive  influence  over  the 
internal  life.  In  manic-depressive  insanity  the  external 
expressions  accompanying  attention  are  usually  preserved, 
the  patients  look  around  inquiringly,  although  not  under- 
standingly.  They  look  at  objects  placed  before  them  and 
turn  the  head  at  a  noise. 

An  immediate  result  of  these  disturbances  of  attention, 
both  blunting  and  retardation,  is  the  loss  of  their  determining 
influence  upon  new  perceptions.  A  single  impression  may 
be  able  to  arouse  the  attention  and  be  strengthened  by  it, 
but  the  persistent  continuance  of  this  psychical  process, 
with  its  resulting  choice  of  the  incoming  perceptions,  is 
lacking.  An  impression  once  aroused  may  last  some  time, 
but  it  can  always  be  displaced  by  a  new  stimulus,  provided 
only  the  latter  is  strong  enough.  This  is  passivity  of  the 
attention  which  is  observed  particularly  in  paresis  and  senile 
dementia.     It  also  occurs  in  the  stuporous  forms  of  manic- 


DISTURBANCES  OF  THE  PROCESS  OF  PERCEPTION    21 

depressive  insanity  and  in  many  of  the  demented  states 
following  infectious  diseases. 

The  patients  resemble  children  who  have  never  had  ex- 
perience, therefore  have  no  ideas  or  memory  pictures  that 
can  be  awakened  to  direct  the  attention.  In  those  forms  of 
mental  weakness,  in  which  mentality  does  not  develop  be- 
yond the  grade  of  childhood,  the  attention  throughout  life 
remains  passive  and  lacks  independence. 

Distractibility  of  attention  is  the  domination  of  the  atten- 
tion by  accidental,  external,  and  internal  influences.  Limi- 
tation of  the  attention  arises  through  the  want  of  ideas  that 
have  strength  enough  to  influence  the  process  of  apprehension; 
in  distractibility  there  is  a  greater  flightiness  of  the  mental 
processes.  The  attention  leaps  from  one  impression  to 
another,  in  spite  of  the  fact  that  an  endeavor  is  made  to 
direct  the  attention.  This  disturbance  regularly  accompa- 
nies those  mental  states  that  exhibit  increased  irritability. 
It  is  probable  that  in  increased  distractibility  of  the  atten- 
tion the  separate  impressions  fade  so  rapidly  that  they 
have  no  dominating  influence  upon  the  incoming  percep- 
tions. Details  are  apprehended  without  a  comprehensive 
view  of  their  relations,  and  the  entire  apprehension  is 
superficial. 

The  lightest  form  of  distractibility  is  found  in  the  absent- 
mindedness  of  fatigue.  In  chronic  nervous  exhaustion  it 
is  more  persistent,  as  is  also  the  case  in  convalescence  from 
severe  physical  or  mental  disease.  It  appears  to  a  marked 
degree  in  the  excited  stages  of  paresis,  sometimes  also  in 
catatonia,  collapse  delirium,  and  in  the  infection  psychoses, 
but  particularly  in  the  manic  forms  of  manic-depressive 
insanity.  In  these  conditions  a  single  word  or  the  most 
casual  stimuli  suffice  to  distract  the  attention. 

Distractibility  of  attention  is  continuously  present  in  some 


22  GENERAL  SYMPTOMATOLOGY 

forms  of  constitutional  psychopathic  states,  where  it  ex- 
erts a  very  powerful  influence  upon  the  mental  development. 
The  more  distractible  a  man  is,  the  less  perception  is  con- 
trolled by  inner  motives  arising  from  experience,  and  the  less 
coherent  and  uniform  is  the  conception  of  the  external  world. 
Distractibility  is  not  to  be  confounded  with  hyperprosexia, 
which  consists  in  the  total  absorption  of  the  attention  by  a 
single  process,  examples  of  which  are  found  in  the  so-called 
absent-mindedness  of  scholars  and  the  complete  absorption 
of  the  melancholia  c  in  his  sad  ideas. 


B.     DISTURBANCES   OF  MENTAL  ELABORATION 

The  material  of  experience,  received  through  the  different 
senses  and  clarified  by  attention,  forms  a  basis  for  all  further 
mental  elaboration,  and  it  is  self-evident  that  both  disturb- 
ances of  apprehension,  and  the  inability  to  make  a  syste- 
matic choice  in  the  impressions,  must  affect  to  a  marked 
degree  the  character  of  all  intellectual  processes. 

Disturbances  of  Memory.  —  All  higher  mental  activity  de- 
pends largely  upon  memory.  Every  impression  which  has 
once  entered  consciousness  leaves  behind  it  a  gradually  fad- 
ing "disposition"  to  its  recall,  which  may  be  accomplished 
either  through  an  accidental  association  of  ideas  or  through 
an  exertion  of  the  will.  This  disposition  to  recollection  is 
really  identical  with  the  residua  which  each  new  perception 
contributes  to  the  store  of  experience  and  to  the  resources  of 
memory.  The  residua  are  strong  and  permanent  in  direct 
proportion  to  the  clearness  of  the  original  impression,  and  to 
the  multiplicity  of  its  relations  to  other  processes,  i.e.  to  the 
interest  it  arouses  and  to  the  frequency  of  its  repetition. 
The  vast  majority  of  our  ideas  and  the  greater  part  of  the 
association  complexes  with  which  we  have  to  do  daily,  are 
so  accessible  to  us  that  they  appear  of  themselves  under  the 
least  provocation  and  without  any  effort. 

Memory  is  really  a  dual  process  dependent  on  impressi- 
bility and  on  retentiveness,  each  of  which  may  be  disturbed 
independently  of  the  other. 

Impressibility  is  the  faculty  for  receiving  a  more  or  less 
permanent  impression  made  by  new  experience.     The  clear 

23 


24  GENERAL  SYMPTOMATOLOGY 

apprehension  of  events,  especially  when  aided  by  active 
attention,  increases  this  impressibility,  while  it  is  lessened 
by  difficulty  of  apprehension,  by  distractibility  and  indiffer- 
ence. It,  therefore,  is  diminished  wherever  there  is  cloudi- 
ness of  consciousness,  as  in  amentia,  to  a  less  extent  in  the 
absent-mindedness  of  fatigue,  and  in  the  states  of  deteriora- 
tion in  dementia  prsecox,  paresis,  and  in  epileptic  insanity, 
which  are  characterized  by  stupid  indifference  to  the  envi- 
ronment. The  most  marked  disturbance  of  impressibility 
occurs  in  Korssakow's  psychosis  and  senile  dementia,  espe- 
cially presbyophrenia,  although  the  moment  impressions  are 
well  apprehended  and  assimilated.  In  these  patients  the 
process  of  perception  develops  very  slowly,  so  that  with 
those  stimuli  which  act  quickly  the  process  of  apprehension 
becomes  distinctly  impaired  and  at  the  same  time  the  pro- 
cesses of  consciousness  fade  very  quickly. 

In  normal  life  it  is  the  greatly  diminished  impressibility 
which  renders  it  difficult  to  recall  our  dreams.  This  demon- 
strates that  psychic  life,  and  therefore  consciousness,  can 
exist  without  memory.  Similar  conditions  of  clouded 
consciousness,  with  undoubted  evidences  of  a  psychic 
activity,  but  yet  without  memory,  occur  in  epilepsy,  many 
delirious  conditions,  profound  intoxications,  and  hypnotism. 
"Retrograde  amnesia,"  in  which  memory  is  more  or  less 
permanently  destroyed  without  clouding  of  consciousness, 
occurs  in  epileptic,  hysterical,  and  paralytic  attacks,  head 
injury,  and  some  attempts  at  suicide,  in  which  patients  can- 
not remember  the  events  which  immediately  precede  the 
attack.     Memory  for  this  period  may  return. 

Retentiveness  of  memory  for  past  events  depends  upon  the 
previous  impressibility,  upon  repetition  and  the  native 
tenacity  of  the  individual  memory.  Its  disturbance  is 
manifested  by  an  inability  to  accurately  recall  former  knowl- 


DISTURBANCES  OF  MENTAL  ELABORATION  25 

edge  and  important  personal  events.  Lack  of  impressibility 
usually  accompanies  lack  of  retentiveness,  but  the  converse 
is  not  necessarily  true,  as  impressibility  is  affected  by  cloud- 
ing of  consciousness,  while  retentiveness  is  not.  In  senility 
the  former  is  far  more  disturbed  than  the  latter;  recent 
events  leave  no  residua,  while  remote  events  recur  in  mem- 
ory with  ease  and  accuracy.  This  is  even  more  striking  in 
senile  dementia  and  may  occur  in  paresis.  In  Korssakow's 
psychosis  the  weakness  of  memory  may  extend  back  to  cover 
a  definite  period  of  the  life. 

The  accuracy  of  memory  may  be  disturbed.  Even  in 
normal  conditions,  accuracy  is  only  relative.  In  morbid 
change  of  personality  or  the  emotions,  and  in  the  develop- 
ment of  delusions,  the  past  is  always  more  or  less  falsified. 
Vivid  imagination  and  pronounced  egoism  imperceptibly 
modify  the  memory  of  past  experience  even  in  normal  life; 
stories  are  embellished  with  interesting  details,  while  the 
self  becomes  a  more  and  more  important  factor.  This  is 
always  exaggerated  in  disease,  while  in  melancholia,  per- 
secutory and  expansive  delusions  often  color  the  memory 
of  the  past  until  it  seems  like  pure  invention. 

A  mixture  of  invention  and  real  experience  is  called 
'paramnesia.  There  also  exist  "hallucinations  of  memory" 
(Sully),  which  consist  of  pure  fabrications,  being  found  espe- 
cially in  paresis,  paranoid  dementia,  and  sometimes  also 
in  maniacal  forms  of  manic-depressive  insanity.  It  also 
occasionally  occurs  in  epileptic  and  hysterical  befogged 
states.  But  fabrications  are  particularly  characteristic  of 
Korssakow's  psychosis,  and  presbyophrenia,  in  which  states 
the  gaps  produced  by  disordered  perception  are  filled  in  with 
falsifications  of  memory,  including  even  incidents  of  youth. 
These  are  often  fantastic  accounts  of  wonderful  adventures ; 
they  may  be  modified  by  suggestion  and  are  frequently  self- 


26  GENERAL  SYMPTOMATOLOGY 

contradictory  (see  p.  186).  The  delusion  of  a  double  exist- 
ence may  be  produced  by  confusing  present  experience 
with  indistinct  memory  images  of  the  past,  so  that  every 
event  seems  like  a  duplicate  of  a  former  experience.  This 
sometimes  occurs  transiently  in  normal  life;  in  disease 
it  may  last  for  months,  and  is  found  particularly  in 
epilepsy. 

Disturbances  of  Orientation.  —  Orientation  is  the  clear 
comprehension  of  the  environment  in  its  temporal,  spacial, 
and  personal  relations.  Our  present  is  related  to  our  past 
experience  in  a  temporal  series  through  the  function  of 
memory.  Only  recent  events  are  remembered  with  the 
greatest  distinctness ;  while  the  rest  is  grouped  around 
more  or  less  isolated  points,  which  form  the  basis  for  the 
general  chronological  arrangement  of  our  experience. 

Spacial  orientation  is  partly  dependent  on  memory.  In 
the  first  place,  memory  enables  us  to  recognize  immediately 
parts  of  our  present  environment,  while  even  an  unknown 
environment  may  be  comprehended  through  our  experience 
when  the  latter  includes  the  motives  or  conditions  for  the 
former.  But  apprehension  may  also  play  an  essential  role 
in  place  orientation.  In  any  unknown  environment  into 
which  one  happens  to  be  placed,  the  process  of  perception 
regularly  clears  up  the  real  situation  by  bringing  about  a 
connection  between  the  immediate  impressions  and  our 
past  experience.  This  often  involves  more  than  a  mere 
identification  of  the  present  with  the  past.  It  may  result 
from  a  more  or  less  complicated  process  of  reflection  and 
reasoning.  In  the  same  manner,  orientation  as  to  persons 
arises  from  the  cooperation  of  memory,  perception,  and 
judgment. 

Thus  it  becomes  apparent  that  lack  of  orientation  or 
disorientation  may  arise  from  disorder  of  memory,  from  dis- 


DISTURBANCES  OF  MENTAL  ELABORATION  27 

order  of  apprehension,  and  from  disorder  of  judgment.  In 
many  cases  two  or  more  of  these  causes  are  combined. 
Further,  the  disorder  may  involve  all  the  fields  of  orienta- 
tion or  it  may  be  limited  to  a  single  field,  so  we  may  dif- 
ferentiate between  total  and  partial  disorientation.  The 
apprehension  of  the  environment  may  be  prevented  by 
the  fact  that  the  patients  cannot  elaborate  their  external 
impressions,  or  by  an  inhibition  of  thought,  or  by  a 
clouding  of  consciousness  with  or  without  falsification  of 
perception.  The  first  case  is  very  common  in  dementia 
praecox,  where  the  disorientation  usually  results  from  the 
lack  of  mental  activity,  and  may  be  called  an  apathetic 
disorientation.  There  is  no  difficulty  in  perception.  The 
patients  simply  lack  the  inclination  to  understand  the 
meaning  of  what  they  see  and  hear,  so  that  for  weeks  at  a 
time  they  may  give  themselves  no  concern  as  to  where 
they  are,  how  long  they  have  been  there,  or  whom  they  see. 
In  the  depressive  phases  of  manic-depressive  insanity 
the  apprehension  of  the  environment  is  rendered  difficult 
through  the  presence  of  retardation  and  there  develops 
a  condition  of  perplexity.  The  patients  perceive  details 
well  enough,  but  they  fail  to  synthesize  them.  The  dis- 
orientation in  the  most  pronounced  manic  states  may 
perhaps  be  similarly  accounted  for,  as  there  accompanies 
it  a  marked  difficulty  in  the  apprehension  and  elaboration 
of  external  impressions.  The  different  forms  of  clouding 
of  consciousness  in  focal  lesions  of  the  brain,  in  epilepsy, 
and  in  alcoholics  cause  a  more  or  less  pronounced  disorder 
of  orientation.  In  the  delirious  states  found  in  infection 
and  intoxication  psychoses,  also  in  hysteria  and  epilepsy, 
there  exist,  besides  the  lack  of  clearness  of  apprehension, 
also  sense  deceptions,  both  of  which  cloud  and  falsify  the 
picture  of  the  environment. 


28  GENERAL  SYMPTOMATOLOGY 

In  Korssakow's  psychosis  there  is  an  amnesic  disorien- 
tation which  depends  neither  upon  disturbances  of  appre- 
hension nor  of  perception.  While  in  this  condition  place 
orientation  is  usually  well  retained,  the  patients  are  abso- 
lutely helpless  as  regards  time.  They  do  not  know  when 
they  came  into  the  institution,  when  they  were  last  visited 
by  relatives,  when  they  last  dined,  etc.  Events  of  a  month 
ago  may  be  referred  to  as  occurring  yesterday,  and  again 
an  occurrence  of  yesterday  may  be  mentioned  as  happen- 
ing months  ago. 

This  amnesic  form  of  disorientation  may  occur  even  more 
strikingly  in  presbyophrenia,  where  on  account  of  the  marked 
disturbance  of  perception  in  connection  with  the  difficulty 
of  apprehension,  mental  elaboration  of  external  impressions 
is  almost  impossible,  hence  patients  fail  to  get  any  idea  of 
their  environment,  although  details  are  understood  without 
difficulty.  The  amnesic  form  of  disorientation  also  occurs 
in  paresis,  where  time  orientation  is  most  often  at  fault. 
Amnesic  disorientation  occurs  in  other  psychoses,  indeed, 
wherever  the  disorder  arises  from  faults  of  memory.  One's 
own  experience  in  orienting  himself  upon  awakening  from 
a  sleep  or  after  fainting  indicates  how  difficult  it  is  to  regain 
time  orientation  after  a  severe  clouding  of  consciousness. 

The  delusional  form  of  disorientation  is  quite  different. 
Here  we  have  to  do  with  a  faulty  mental  elaboration  of  im- 
pressions which  are  correctly  perceived  and  apprehended, 
leading  to  a  false  opinion  as  to  the  environment  in  its  tem- 
poral and  spacial  relations.  The  patients  are  not  clouded, 
but  they  maintain  delusional  ideas  as  to  the  time,  place, 
and  persons.  Illusions  or  hallucinations  may  be  the  basis 
for  such  beliefs,  as  in  mistaken  personalities  and  the  asser- 
tions of  paranoid  patients  that  they  are  in  prison,  in  a  bad 
house,  etc. 


DISTURBANCES  OF  MENTAL  ELABORATION  29 

Disturbances  of  the  Formation  of  Ideas  and  Concepts.  — 
Most  of  the  complex  ideas  of  normal  life  are  composed  of 
heterogeneous  elements,  furnished  by  the  various  senses.  In 
these  complexes  the  importance  of  the  material  furnished  by 
any  one  sense  depends  upon  the  peculiarities  of  the  individ- 
ual. For  some,  vision  is  the  most  important  sense,  for  others 
audition;  but  both  of  these  senses  may  be  entirely. lacking 
without  preventing  a  high  development  of  ideation.  On  the 
other  hand,  lack  of  permanence  of  sensory  impressions  and 
imperfect  assimilation  always  interfere  with  the  formation 
of  complex  ideas.  This  is  illustrated  in  congenital  and 
acquired  imbecility. 

The  formation  of  concepts  is  the  necessary  condition  for  the 
fullest  development  of  ideation.  In  normal  life  those  ele- 
ments of  experience  which  are  often  repeated  impress  them- 
selves more  and  more  strongly,  while  the  accidental  varia- 
tions of  each  individual  experience  are  driven  more  and 
more  into  the  background.  The  concepts  thus  developed 
are  a  sort  of  composite  photograph  or  generalization  of 
experience. 

These  concepts  are  the  most  permanent  and  most  easily 
reproduced  of  all  our  ideational  processes.  But  even  these 
may  not  be  reproduced  in  totality.  More  and  more  in  the 
developed  consciousness  single  elements  of  these  concepts 
are  made  to  stand  for  the  whole.  The  exact  form  of  this 
abbreviation  of  thought  is  often  accidental,  as  when  some 
single  image  comes  to  stand  for  the  total  concept.  The 
highest  form  of  this  development  is  found  in  the  abbrevia- 
tion of  thought  by  the  use  of  linguistic  symbols,  i.e.  when  a 
word  stands  for  the  idea. 

In  morbid  conditions,  especially  in  congenital  imbecility, 
this  development  may  stop  at  any  point.  The  patients 
may  cling  to  individual  experience  without  being  able  to 


30  GENERAL  SYMPTOMATOLOGY 

sift  out  the  general  characteristics  of  different  impressions 
of  a  similar  nature.  They  are  unable  to  find  concise  ex- 
pressions for  more  extended  experience;  the  essential  is 
not  distinguished  from  the  unessential,  the  general  from  the 
particular. 

This  not  only  prevents  the  development  of  thought,  but 
it  also  retards  the  assimilation  of  new  material.  New  im- 
pressions find  no  point  of  attachment  in  the  mental  life; 
they  cannot  be  arranged  or  systematized,  and  pass  rapidly 
into  oblivion.  In  acquired  imbecility  the  residua  of  earlier 
experience  may  partly  conceal  the  inability  to  receive  new 
impressions  and  to  form  new  ideas.  Later,  however,  this 
defect  gradually  becomes  more  evident.  Similarly  in 
paresis,  dementia  prsecox,  and  senile  dementia,  the  circle 
of  ideas  narrows,  and  general  ideas  and  concepts  are  gradu- 
ally replaced  by  the  specific,  the  immediate,  and  the  tangible. 
New  impressions  are  no  longer  elaborated  and  the  most 
recent  experience  is  quickly  forgotten,  while  the  memory 
of  the  past  is  still  fairly  constant. 

In  direct  contrast  to  this  is  the  disturbance  produced  by 
morbid  excitability  of  the  imagination,  which  correlates  dis- 
similar and  even  contradictory  ideas.  Such  forced  and 
arbitrary  combinations  naturally  interfere  with  the  normal 
development  of  concepts.  Thus  the  foundation  of  all  higher 
mental  activity  becomes  a  mass  of  confused  and  indistinct 
psychic  structures,  which  can  give  rise  only  to  one-sided 
and  mistaken  judgments  as  soon  as  the  patients  leave 
the  region  of  immediate  sensory  experience.  The  tendency 
to  reveries  and  dreams,  lack  of  appreciation  of  facts,  im- 
possible plans  and  chimeras,  so  often  found  in  imbecility, 
paresis,  and  paranoid  dementia,  are  clinical  forms  of  this 
disturbance. 

Disturbances  of  the  Train  of  Thought. — The  association  of 


DISTURBANCES  OF  MENTAL  ELABORATION  31 

ideas  may  be  divided  into  two  groups :  external  and  internal 
associations,  the  former  being  effected  by  purely  external 
or  accidental  relations,  while  the  latter  arise  from  a  real 
coherence  in  the  content  of  the  ideas. 

External  associations  usually  arise  through  the  customary 
connection  of  ideas  in  time  or  space,  of  which  thunder  and 
lightning  is  an  example;  or  through  habits  of  speech,  in 
which  a  definite  association  of  words  becomes  so  fixed  by 
frequent  repetition  that  one  word  always  calls  up  the  others, 
as  in  quotations  and  stereotyped  phrases.  Sound  associa- 
tions, an  important  and  extreme  form  of  this  type,  are  based 
either  upon  similarity  of  sound  or  of  the  movements  of  the 
vocal  organs,  as  seen,  for  example,  in  a  morbid  tendency 
to  rhyme.  This  disturbance  may  be  so  marked  that  the 
associated  sounds  are  altogether  meaningless. 

Internal  associations  depend  upon  the  logical  arrange- 
ment of  our  ideas  according  to  their  meaning.  The  asso- 
ciation between  different  individuals  of  the  same  species, 
or  different  species  of  the  same  class,  is  of  this  kind;  for 
instance,  the  association  of  boy  with  man  and  man  with 
animal,  etc.  The  special  form  of  internal  associations, 
which  emphasize  some  particular  characteristics  of  a  con- 
cept, usually  attributes,  states  of  being,  or  activities,  by 
means  of  which  a  preceding  idea  is  more  closely  defined, 
is  called  predicative  association.  That  the  dog  is  an 
animal  belongs  to  the  first  class  of  internal  associations; 
that  he  is  dark-colored,  or  that  he  runs,  belongs  to  the 
second. 

Paralysis  of  thought,  the  simplest  form  of  disturbance  of 
the  train  of  thought,  is  characterized  by  complete  absence 
of  all  associations.  It  begins  as  a  more  or  less  marked  re- 
tardation, and  develops  into  characteristic  monotony  and 
distractibility  of  thought.     It  occurs  in  a  moderate  degree 


32  GENERAL  SYMPTOMATOLOGY 

in  fatigue.  Narcotic  poisoning  presents  severer  forms.  It 
is  a  fundamental  symptom  in  the  psychoses  accompanied 
by  deterioration:  paresis,  dementia  prsecox,  and  senile  de- 
mentia. 

Retardation  of  thought  is  manifested  by  difficulty  in  the 
elaboration  of  external  impressions ;  the  train  of  thought  is 
markedly  retarded,  and  the  control  of  the  store  of  ideas  is  in- 
complete. It  may  bring  the  train  of  thought  to  a  complete 
standstill.  In  contrast  to  the  paralysis  of  thought,  to  which 
it  presents  a  superficial  similarity,  this  inhibition  may 
suddenly  disappear  under  certain  conditions,  as  fear.  The 
patients  do  not  lack  mental  ability ;  they  are  not,  like  the 
weak-minded  or  deteriorated,  obtuse  and  indifferent,  but 
they  are  unable  to  overcome  this  restraint  which  they  them- 
selves very  often  realize.  The  most  pronounced  form  of 
this  disturbance  is  seen  in  the  depressed  and  mixed  forms 
of  manic-depressive  insanity,  and  perhaps,  also,  in  the  dis- 
turbance of  thought  in  epileptic  stupor. 

The  disturbances  of  the  content  of  thought  are  best  under- 
stood as  a  faulty  arrangement  of  the  individual  links  of  our 
thought  with  relation  to  the  goal  ideas.  Normal  thought 
is  usually  directed  by  definite  goal  ideas,  and  of  the  ideas 
which  appear  in  consciousness,  those  elements  are  specially 
favored  which  stand  in  closest  relation  to  these  controlling 
goal  ideas.  Out  of  the  large  number  of  possible  associations 
those  only  really  occur  which  lie  in  the  direction  determined 
by  the  general  goal  of  the  thought  process. 

In  morbid  conditions  the  train  of  thought  may  be  inter- 
rupted by  individual  ideas,  or  other  trains  of  thought  with 
an  especially  prominent  emotional  tone  (cf.  Melancholia, 
p.  355).  The  memory  of  some  sad  experience  or  a  fright 
may  so  dominate  us  that  our  thoughts  in  spite  of  all  effort 
return  to  the  same  channel. 


DISTURBANCES  OF  MENTAL  ELABORATION  33 

Compulsive  ideas  are  those  ideas  which  irresistibly  force 
themselves  into  consciousness.  These  are  usually  accom- 
panied by  a  disagreeable  feeling  of  subjection  to  some 
overwhelming  external  compulsion.  The  mere  fear  of  their 
recurrence  is  often  sufficient  to  bring  them  into  conscious- 
ness. They  usually  develop  on  a  basis  of  emotional  dis- 
turbance, and,  therefore,  accompany  melancholia  and  de- 
pressed phases  of  manic-depressive  insanity,  also  sometimes 
the  depressive  states  of  dementia  praecox.  The  content  of 
these  impulsive  ideas  is  unpleasant  and  harassing.  The 
patients  are  compelled  to  think  constantly  of  some  shocking 
experience,  which  they  have  had,  or  to  depict  some  mis- 
fortune, which  may  befall  them.  The  profound  emotional 
despondency  which  serves  as  a  basis  for  these  thoughts  and 
at  the  same  time  furnishes  a  good  soil  for  their  develop- 
ment has  associated  with  it  a  feeling  of  compulsion.  As  the 
disease  develops,  despondency  becomes  more  predominant, 
particularly  if  the  resistance  of  the  patient  to  the  ideas  is 
gradually  weakened,  so  that  the  feeling  of  subjection  van- 
ishes. In  this  way  the  original  compulsive  ideas  are  trans- 
formed into  delusions. 

If  the  fundamental  emotional  state  is  independent  of 
morbid  changes  of  the  emotions,  as  encountered  in  various 
psychoses,  the  disturbing  factor  in  the  compulsive  ideas  does 
not  reside  so  much  in  their  content  as  in  the  fact  of  their 
constant  recurrence.  The  most  striking  forms  of  these  com- 
pulsive ideas  develop  in  the  states  of  hereditary  degeneracy 
(cf.  Compulsive  Insanity,  p.  498).  Increased  emotional  sus- 
ceptibility, as  well  as  a  tendency  to  morbid  introspection,  are 
the  fundamental  states  from  which  these  compulsive  ideas 
develop.  In  the  very  lightest  forms  there  develop  ideas 
which  are  unpleasant. 

There  is   still   another   group   of   cases    in  which  some 


34  GENERAL   SYMPTOMATOLOGY 

simple  common  ideas  interfere  with  the  development 
of  every  train  of  thought,  later  gaining  mastery ;  such  as 
the  compulsion  to  recall  the  name  of  some  one,  which  may 
become  so  prominent  that  the  patient  makes  out  a  long  list 
of  names,  and  finally  indexes  the  names  of  every  person 
whom  he  meets.  The  compulsion  to  count  is  of  the  same 
sort  and  again  there  is  the  compulsion  to  ask  of  them- 
selves all  sorts  of  questions  (Gruebelsucht)  (cf.  p.  500). 
There  is  here  a  feeling  of  uncertainty  which  incites  the 
patient  to  a  distinct  effort,  which  feeling  can  never  be 
quite  satisfied,  because  every  suggestion  leads  to  still  an- 
other series.  There  is  no  end  to  the  names,  the  numbers, 
and  the  questions  to  be  asked.  The  real  basis  for  these  ideas 
is,  therefore,  a  feeling  of  discomfort,  identical  with  that 
which  incites  all  of  us  to  seek  for  clearness  and  truth ; 
but  in  the  case  of  the  patient  these  ideas  are  no  longer 
the  servants,  but  are  masters  of  the  psychical  personality, 
because  he  has  not  the  power  to  suppress  them  when  they 
hinder  the  train  of  thought. 

Distinguished  from  the  compulsive  ideas  are  the  simple 
persistent  ideas,  unaccompanied  by  marked  unpleasant  feel- 
ings of  compulsion.  This  phenomenon  is  probably  due  to 
the  absence  of  definite  or  fixed  goals  in  the  train  of 
thought  — a  view  which  is  borne  out  by  our  experience 
with  the  persistence  of  some  of  our  own  ideas,  whenever  we 
give  free  rein  to  our  thoughts.  Rhyme,  verses,  and  melo- 
dies sometimes  cling  to  us  even  in  spite  of  our  efforts  to 
throw  them  off. 

In  gross  brain  lesions  there  is  often  found  a  peculiar 
persistency  of  linguistic  expressions.  Words  and  phrases 
used  shortly  before  are  repeated  by  mistake.  Patients  in 
naming  objects  use  words  which  they  have  just  heard  or 
spoken.     Fatigue  may  so  aggravate  this  disorder  that  it  is 


DISTURBANCES  OF  MENTAL   ELABORATION  35 

impossible  to  secure  a  correct  answer,  as  one  gets  only  a 
monotonous  repetition  of  previous  statements. 

In  another  phase  of  the  disorder,  more  or  less  motor  to 
be  sure,  patients  use  an  indicated  object  in  the  same  way 
they  have  just  previously  and  correctly  used  another. 
Neisser  happily  names  this  disturbance  perseveration.  In 
some  cases  of  senile  dementia  with  pronounced  persist- 
ency of  ideas,  Schneider  has  pointed  out  that  ideas  once 
aroused  develop  very  slowly.  In  fact,  in  perseveration, 
one  often  has  the  impression  that  the  patients  fail  to  un- 
derstand the  new  perceptions  and  when  forced  simply  repeat 
themselves.  Patients  only  named  a  picture  right  after  one 
or  two  other  pictures  had  been  shown.  If  this  hypothesis 
is  correct,  the  disorder  is  conditioned  not  so  much  by  the 
peculiar  stubbornness  of  a  particular  idea,  but  rather  by 
the  difficulty  of  releasing  other  ideas  to  displace  it. 

One  should  distinguish  carefully  from  perseveration  the 
tendency  "to  run  to  death  the  same  ideas"  so  often  occur- 
ring in  dementia  praecox  in  a  pronounced  form.  It  is  but 
another  expression  of  stereotypy  of  the  will.  Examples  of 
this  condition  may  occasionally  be  encountered  in  children. 
It  consists  of  an  impulsive,  often  limitless  repetition  of 
similar  expressions,  sometimes  alone  and  sometimes  inter- 
woven in  other  more  or  less  incoherent  trains  of  thought. 
The  content  of  these  stereotyped  ideas  is  quite  accidental 
and  is  not,  as  in  simple  persistent  ideas,  determined  by 
that  which  has  preceded. 

In  morbid  conditions,  even  when  the  collection  and 
elaboration  of  new  impressions  is  prevented  by  mental 
disease,  there  remain  some  residual  ideas  of  the  normal 
state,  fixed  by  constant  repetition.  This  results  in  a 
monotonous  content  of  consciousness  with  a  marked  im- 
poverishment of  the  store  of  ideas.     This  occurs  in  senility, 


36  GENERAL  SYMPTOMATOLOGY 

paresis,  and  other  deterioration  processes,  in  which  the 
train  of  ideas  may  shrink  down  to  a  few  phrases,  or  even 
a  few  words  which  are  repeated  over  and  over.  These 
phrases,  in  contrast  to  the  persistent  ideas  of  the  catatonic, 
are  not  senseless,  but  actually  express  the  content  of  the 
patient's  consciousness.    The  following  is  an  example: — 

"  Frazier  went  away  this  morning,  will  be  back  soon.  Didn't  ask 
him  what  time  he'd  come  home.  Frazier  is  working  up  in  the  lot 
at  something.  I  was  up  in  the  lot  yesterday.  I  forget  what  I 
went  for.  Frazier  is  talking  of  selling  the  place.  He  asked  me 
what  I  cared  about  it.  Father  is  going  over  there  to-day.  Father 
don't  care  for  the  farm.  He  didn't  speak  to  me ;  he  is  downhearted. 
He  should  bring  up  his  boys  to  work  upon  it.  Frazier  don't  have 
time  to  work.  He  don't  stay  home  much.  I  would  advise  them 
to  have  a  place  and  keep  it.  If  I  get  well  I  will  keep  it,  if  I  can. 
The  boys  would  like  to  have  some  farm.  They  won't  stay  in  a  place. 
Frazier  don't  like  to  work  on  the  farm.  [Patient  hears  a  woman 
coming  up  the  hall.]  Some  woman  I  hear  coming.  If  she  was  on 
a  farm,  she  wouldn't  handle  much  money.  If  they  sell  the  place, 
the  children  will  starve  for  hunger.  [Patient  looks  at  her  hand.] 
I  am  all  blacked  up.  I  have  been  out  on  the  farm  a  good  deal. 
If  he  sells  the  place,  the  little  children  will  starve  for  hunger, "  etc. 

Circumstantiality  is  the  interruption  of  the  course  of 
ideas  by  the  introduction  of  a  great  multitude  of  non- 
essential accessory  ideas,  which  both  obscure  and  delay  the 
train  of  thought.  The  disturbance  depends  upon  a  defec- 
tive estimation  of  the  importance  of  the  individual  ideas 
in  relation  to  the  goal  ideas.  The  goal  may,  indeed,  be 
ultimately  obtained,  showing  some  real  coherence,  but 
only  after  many  detours.  The  simplest  form  of  circum- 
stantiality appears  in  the  prolixity  of  the  uneducated, 
who  are  unable  to  arrange  their  general  ideas  in  accord- 
ance with  their  importance,  and  show  a  tendency  to  adhere 
to  details.    Some  even  have  difficulty  in  distinguishing 


DISTURBANCES  OF  MENTAL  ELABORATION  37 

sharply  what  is  actually  seen  from  what  is  simply  imagined. 
The  circumstantiality  of  the  senile  is  probably  due  to  the 
disappearance  of  the  general  ideas  and  concepts.  Circum- 
stantiality is  also  present  to  a  marked  degree  in  epileptic 
insanity,  of  which  the  following  passage  taken  from  the 
bibliography  of  an  epileptic  is  an  example :  — 

"  Before  one  believes  what  others  have  told  him  or  what  he  has 
read  in  the  almanacs  he  must  be  convinced  and  examine  himself 
before  one  can  say  and  believe  that  a  thing  is  beautiful  or  that  a  thing 
is  not  beautiful ;  first  investigate,  go  through  it  yourself,  and  examine 
it,  and  then,  when  man  has  investigated  everything  and  has  gone 
through  it  himself  and  examined  it,  then  man  can  at  once  say  the 
thing  is  beautiful  or  is  not  beautiful  or  not  good ;  therefore,  I  myself 
say,  if  one  will  make  a  statement  about  a  thing,  or  will  sufficiently 
establish  something  or  will  speak  in  conformity  with  the  truth,  the 
thing  is  right  or  is  not  right,  so  must  every  man  likewise  examine 
the  thing  as  he  believes  himself  responsible  before  the  tribune  God, 
and  before  his  Majesty  the  King  of  Prussia,  William  the  Second, 
and  the  Emperor  of  Germany.  I  will  now  relate  further  what  the 
soldiers  have  done  to  me.  " 

The  absence  or  incomplete  development  of  goal  ideas 
gives  rise  clinically  to  two  important  forms  of  disturbance 
of  the  train  of  thought:  (1)  flight  of  ideas,  (2)  desultori- 
ness.  The  first  effect  of  a  defective  control  over  the  train 
of  ideas  is  a  frequent  and  abrupt  change  of  direction.  The 
train  of  thought  will  not  proceed  systematically  to  a  defi- 
nite aim,  but  constantly  falls  into  new  pathways  which 
are  immediately  abandoned  again.  The  impetus  for  such 
changes  of  direction  can  arise  from  both  external  stimuli 
and  from  internal  processes. 

In  flight  of  ideas  the  instability  of  goal  ideas  produces 
a  condition  in  which  the  successive  links  of  the  chain  of 
thought  stand  in  fairly  definite  connection  with  each  other, 
but  the  whole  course  of  thought  presents  a  most  varied 


38  GENERAL  SYMPTOMATOLOGY 

change  of  direction.  The  patient  is  unable  to  give  long 
answers  to  questions,  and  cannot  be  held  to  a  problem 
requiring  much  mental  work,  because  ideas  once  aroused 
are  immediately  forced  into  the  background  by  others. 
This  is  a  fundamental  symptom  of  the  manic  form  of 
manic-depressive  insanity,  and  also  occurs  in  acute  exhaus- 
tion psychoses,  infection  deliria,  paresis,  occasionally  also  in 
fatigue  of  normal  life  and  especially  in  dreams.  It  may 
appear  in  alcoholic  intoxication.  There  is  no  great  wealth 
of  ideas,  but  on  the  contrary  it  is  often  accompanied  by 
a  conspicuous  poverty  of  thought.  Moreover,  the  rapidity 
of  the  association  of  ideas  is  not  at  all  increased,  but 
on  the  other  hand  is  usually  diminished.  The  patient's 
incoherence,  therefore,  depends  simply  on  the  lack  of  that 
unitary  control  of  the  association  of  ideas  which  represses 
all  secondary  ideas  and  permits  progress  only  in  a  definite 
direction.  As  the  result  of  this,  any  accidental  idea  which 
would  normally  inhibit  the  goal  idea  may  assume  impor- 
tance. It  is  not,  then,  the  rapid  succession  of  ideas  which 
warrants  the  designation  of  a  flight  of  ideas,  but  the  insta- 
bility of  single  ideas  which  are  unable  to  exert  any  influ- 
ence over  the  course  of  the  train  of  thought. 

In  flight  of  ideas  the  direction  of  the  train  of  thought 
is  determined  by  external  impressions,  chance  ideas,  or 
finally  by  simple  associations,  external  or  internal.  The 
influence  of  chance  ideas  is  well  demonstrated  in  intoxica- 
tion deliria,  and  especially  in  opium  intoxication,  in  which 
vivid  ideas  of  the  imagination  follow  each  other  in  a  varie- 
gated series,  giving  rise  to  an  incoherent  progression  of 
unrelated  fancies,  to  which  experience  offers  no  key.  This 
might  be  called  the  delirious  form  of  flight  of  ideas. 

The  rambling  thought  of  the  hypomaniacal  patient  is 
another  form  of  the  flight  of  ideas  in  which  the  patients 


DISTURBANCES  OF  MENTAL  ELABORATION  39 

are  diverted  by  unimportant  ideas,  reminiscences,  and 
incidents,  and  need  to  be  frequently  led  back  to  their  sub- 
ject. The  following  is  an  example  (the  patient  being  asked 
when  she  left  the  Hartford  Retreat) :  — 

"  My  mother  came  for  me  in  January.  She  had  on  a  black  bom- 
bazine of  Aunt  Jane's.  One  shoestring  of  her  own  and  got  an- 
other from  neighbor  Jenkins.  She  lives  in  a  little  white  house 
kitty  corner  of  our'n.  Come  up  with  an  old  green  umbrella  'cause 
it  rained.  You  know  it  can  rain  in  January  when  there  is  a  thaw. 
Snow  wasn't  more  than  half  an  inch  deep,  hog  killing  time,  they 
butchered  eight  that  winter,  made  their  own  sausages,  cured  hams, 
and  tried  out  their  lard.  They  had  a  smoke  house.  [But  how 
about  your  leaving  Hartford?]  She  got  up  to  Hartford  on  the 
half-past  eleven  train  and  it  was  raining  like  all  get  out.  Dr. 
Butler  was  having  dinner,  codfish,  twasn't  Friday,  he  ain't  no 
Catholic,  just  sat  with  his  back  to  the  door  and  talked  and  laughed 
and  talked. " 

Here,  in  spite  of  many  diversions,  we  see  a  fairly  good 
sequence  in  the  content  of  thought  which  centers  around  a 
visit  of  the  patient's  mother. 

In  the  following  example,  on  the  other  hand,  the  pre- 
dominance of  motor  speech  ideas  has  led  to  a  massing 
of  habitual  speech  associations,  combinations  of  common 
words,  and  finally  to  simple  sound  associations.  It  might 
be  called  an  external  flight  of  ideas  in  contrast  to  an  internal 
flight  of  ideas  characterized  by  internal  associations. 

"  I  was  looking  at  you,  the  sweet  boy,  that  does  not  want  sweet 
soap.  You  always  work  Harvard  for  the  hardware  store.  Neat- 
ness of  feet  don't  win  feet,  but  feet  win  the  neatness  of  men. 
Run  don't  run  west,  but  west  runs  east.  I  like  west  strawberries 
best.     Rebels  don't  shoot  devils  at  night. " 

The  train  of  thought  is  supplanted  by  fixed  and  familiar 
phrases,  in  which  the  influer/ce  of  linguistic  ideas  clearly 


40  GENERAL  SYMPTOMATOLOGY 

outweighs  that  of  the  content  of  thought;  while  sound 
associations,  rhymes,  and  quotations,  etc.,  stifle  all  internal 
associations.  The  most  favorable  condition  for  the  appear- 
ance of  ;this  form  is  an  increased  motor  excitability  and 
alcoholic  intoxication. 

Desultoriness,  the  second  form  of  this  type  of  incoherent 
speech,  is  more  difficult  to  characterize,  as  it  is  not  well 
understood.  In  it  the  external  form  of  speech  is  fairly 
well  retained,  but  there  seems  to  be  a  complete  loss  of  goal 
ideas,  while  an  incoordinate  mass  of  ideas  follow  each 
other  aimlessly  and  abruptly.  In  the  flight  of  ideas  we 
were  able  to  discover  some  connection,  if  only  the  most  ex- 
ternal, between  the  separate  links  of  ideas,  which  gradually 
led  to  a  new  chain,  until  the  original  standpoint  was  en- 
tirely lost  sight  of.  In  desultoriness  there  is  no  recog- 
nizable association  between  the  successive  ideas,  while  the 
trains  of  thought  often  move  along  for  some  time  in  simi- 
lar phrases.  They  are  confused  and  contradictory.  In 
flight  of  ideas  the  course  always  tends  toward  changing 
and  hence  never  attained  goals,  and  is,  therefore,  always 
entering  new  circles;  in  this  form,  on  the  other  hand,  the 
train  of  thought  does  not  progress  at  all  in  any  one  direc- 
tion, but  only  wanders  with  numerous  and  bewildering 
digressions  in  the  same  general  paths,  the  following  of 
which  is  an  example :  — 

Middletown,  Dec.  15,  1901. 
Dear  Sister  :  — 

I  received  your  box  in  perfect  shape  and  money  as  well.  Do 
you  wish  to  see  me.  If  you  care  or  somebody  else  will.  Do.  Awful 
lonesome.  A  new  suit  and  fair  words.  This  time  give  me  a  little 
money  if  you  will  (tell  her  to  use  slang  my  front  yard).  Give  me 
a  punch  for  fun.  You  are  read  that  way)  leave  (Give  her  a  drop 
of  your  poison).     Latest  song  attendant.     (Give  her  a  wife  she  is 


DISTURBANCES  OF  MENTAL  ELABORATION  41 

lonesome).  Hill  St.  I  suppose  Tom  Kellhams  Pete  whair  Fitch. 
Right  tell  me  give  over  Pa  Ma  Nell  Har.  Will  Eddy.  I  strong 
don't  you  know  he  passed  it  to  the  other  young  from  Newark  but 
he  could  not  start  it.  He  did  not  know  where  it  came  from.  He 
sleeps  under.  I  got  McKingleys  Son  over  me  at  times  he  works  on 
the  stylish  horse.  He  is  a  black  strong.  I  am  a  red.  You  know 
the  Pres.  Brokerage  and  drink  cigars  and  walks,  speeches.  He  is 
37  Port  Rhoda  he  served  10  years  at  his  trade  he  is  working  14 
good  mack.  Tell  Burnie  he  is  liked  by  him  but  not  strong  enough 
they  live  9,000  miles  in  the  air  over  the  three  miles  you  read  in 
school.  ...  Pa  Pa  you  know  the  stove  he  carried.  1,700  lb. 
trunk  strong  nature,  hard  life  when  I  got  to  let  him  know  how  on 
pipe  here  through  the  converser  the  head  electro  gave  me  a  dime 
for  sense  and  they  don't  speak  and  it  was  a  corn  sense.  I  am  bed 
now  good  by.  Yours  Aff . 

Distractibility  through  internal  and  external  influences 
may  also  be  present  to  a  marked  degree,  but  the  newly 
aroused  ideas  do  not  serve  as  bases  for  others,  but  simply 
intrude  into  the  desultory  train  of  thought  in  an  incoherent 
manner.  In  this  way  it  is  often  possible,  in  the  midst  of 
their  incoherent  jumble,  to  obtain  coherent  replies  to 
questions.  The  following  is  an  example  of  this  (the  phy- 
sician's questions  are  enclosed  in  brackets) :  — 

"  [Why  are  you  here  ?]  Because  I  am  the  empress.  The  dear 
parents  were  already  there  and  everything  was  already  there  and 
had  given  me  permission.  I  have  also  learned  stenography.  Why, 
David,  how  are  you?  Even  a  member  of  the  reserve,  megalo- 
mania, empress.  [Do  you  feel  well  ?]  Oh,  thanks,  very  well,  since 
the  government  has  given  me  permission  we  will  be  good  friends. 
Oh,  God  !  my  brother  Carl  David  the  first  and  Olga.  Ah,  let  me 
write  something.  [Why  are  you  here  ?]  Insane.  Megalomania. 
[What  is  that?!  Nothing,  nothing,  at  all.  [How  old  are  you?] 
22-7-1872.  [Will  you  come  again  ?]  I  do  not  know.  When  he 
comes  I  will  not  run  after  him  (laughs).  I  must  always  be  close 
(clasps  her  hands).  I  have  nothing  (grasps  at  the  watch  chain. 
But  the  chain  is  nothing.    How  I  will  at  once  see  what  time  it  is. " 


42  GENERAL  SYMPTOMATOLOGY 

This  example  does  not  show,  however,  the  repetition  of 
single  words  or  phrases  which  so  frequently  occur  in  the 
catatonic  productions,  and  is  shown  in  the  following :  — 

"You  don't  own  this  building,  I  know  that.  The  Hartford 
pigpen  never  supported,  never  confirmed  food,  therefore  are  not 
supported  and  this  building  will  pay  for  that  and  food  which  con- 
firmed it.  White  immortal  eternal  receipt  for  that  food.  The  war 
planet  Mars.  I  have  the  white  immortal  eternal  receipt.  Mars 
war  planet,  or  war  world  Mars.  The  war  world  or  the  war  planet 
Mars.  White  immortal  eternal  receipt  for  its  existence  and  con- 
firmation receipt.  The  Hartford  pigpen  is  not  supported  or  has 
not  confirmed  food  or  the  laws  of  food,  therefore  will  not  be  sup- 
ported by  those  who  have  confirmed  food.  The  white  immortal 
eternal  receipt." 

In  extreme  desultoriness  the  speech  consists  of  a  mere 
series  of  letters,  syllables,  or  sounds,  while  in  the  severest 
forms  of  flight  of  ideas  there  is  always  some  goal  idea  even 
though  it  rapidly  changes,  and  the  majority  of  the  expres- 
sions consist  of  actual  words;  here  there  is  a  perfectly 
senseless  repetition  of  the  same  sounds  with  only  insignifi- 
cant modifications,  like  the  following:  — 

"  Ellio,  ellio,  ellio  altomellio-altomellio,  —  selo,  eloo,  devo,  heloo 

—  f.  f.  f .  dear  father,  f .  f .  f .  dear  father,  e.  e.  f .  old  and  new  —  f .  f .  f . 

—  f.  f.  —Catholic  Church," 

and  so  on  in  monotonous  repetition.  Sound  associations 
seem  to  play  an  important  role  here,  but  the  train  of 
thought  does  not  advance  through  it  to  new  ideas. 

These  disturbances  which  destroy  or  interrupt  the  inter- 
nal coherence  of  thought  gives  rise  to  what  is  called  con- 
fusion of  thought,  which  is  a  prominent  symptom  of  mental 
disease.  This  symptom  develops  variously.  If  the  inter- 
ference with  the  coherence  of  thought  arises  from  flightiness 
of  the  goal  ideas,  then  we  have  a  form  of  confusion  charac- 


DISTURBANCES  OF  MENTAL  ELABORATION  43 

terized  by  flight  of  ideas  with  its  tendency  to  external  and 
verbal  associations.  The  abrupt  development  of  many  differ- 
ent ideas  without  order,  and  not  leading  to  any  definite  goal 
idea,  gives  rise  to  the  desultory  confusion.  There  may  also 
be  differentiated  still  another  form  of  confusion,  dreamy 
confusion,  which  is  characteristic  of  delirious  states.  In 
this  type  there  exists  besides  the  disturbance  of  appre- 
hension and  the  rapid  fading  away  of  the  perceptions,  a 
marked  prominence  of  sensory  elements  in  thought.  There 
is  also  a  combined  form  of  confusion,  in  which  there  is  a 
transitory  appearance  of  abundant,  new  trains  of  thought 
following  each  other  incoherently.  The  head  fairly  swims 
because  there  is  not  an  opportunity  to  marshal  or  survey 
the  rapidly  appearing  ideas.  This  type  of  confusion  charac- 
terizes those  forms  of  mental  disease  in  which  the  rapidly 
appearing  thoughts  are  elaborated  into  a  permanent 
delusion  formation,  in  the  same  way  that  in  normal  life 
a  person  gradually  works  into  his  train  of  thought  a  new 
idea  that  at  first  was  confused.  Also  the  presence  of  many 
hallucinations  may  be  regarded  as  a  cause  of  an  hallucina- 
tory confusion,  just  as  a  normal  person  sometimes  loses  his 
orientation  if  he  is  suddenly  placed  in  an  inextricable 
environment  with  new  and  puzzling  impressions. 

Mental  retardation  can  also  produce  a  form  of  confusion 
of  thought,  through  the  slowing  of  the  process  of  com- 
prehension and  mental  elaboration.  This  has  been  desig- 
nated stuporous  confusion.  In  it  one  sometimes  encounters 
a  combination  with  a  genuine  flight  of  ideas.  Finally  the 
emotional  attitude  may  play  a  very  important  role  in  the 
development  of  different  forms  of  confusion  of  thought. 
In  some  diseased  mental  states  with  marked  disturbances 
of  the  emotions,  this  element  is  of  great  importance. 

Disturbances  of  Imagination.  —  The  fund  of  our  earlier 


44  GENERAL  SYMPTOMATOLOGY 

experience  becomes  of  most  value  to  us  when  we  are  able  to 
bring  from  it  into  consciousness  voluntary  ideas  and  mem- 
ory images.  This  ability  is  provisionally  named  imagina- 
tion. It  requires  on  the  one  hand  reproducible  residua  of 
former  mental  processes,  and  on  the  other  hand  that  process 
which  enables  us  to  formulate  new  mental  pictures  out  of 
the  simple  residua  of  memory  and  make  it  possible  to  ele- 
vate ourselves  above  our  simple  sensory  experience  and 
perform  original  mental  work. 

The  power  of  imagination  may  be  seriously  disturbed  in 
disease.  In  some  degree  this  is  observed  in  simple  mental 
fatigue,  also  in  poisoning  with  narcotic  and  hypnotic  drugs, 
but  more  especially  in  the  severe  grades  of  deterioration 
found  in  paresis,  senile  dementia,  and  other  mental  dis- 
eases. In  these  latter  disturbances  the  atrophy  of  the 
imagination  is  usually  combined  with  defective  memory. 
The  ideas  are  not  only  not  at  one's  disposal,  but  they  may 
also  in  large  numbers  disappear.  Where  this  loss  is  less 
extensive,  as,  for  instance,  often  in  epileptic  insanity,  there 
develops  a  simple  sluggishness  (Schwerfalligkeit).  These  pa- 
tients still  have  some  command  of  their  store  of  ideas,  but 
they  require  a  very  long  time  and  considerable  stimulation. 

The  retardation  which  is  encountered  in  the  depressive 
and  mixed  phases  of  manic-depressive  insanity  is  to  all 
external  appearances  similar  to  sluggishness.  The  disturb- 
ance of  thought  processes  of  the  befogged  states  of  epileptic 
and  hysterical  insanities  probably  also  belong  here.  Retar- 
dation differs  from  sluggishness  in  that  it  is  a  transitory 
state,  while  the  latter  is  a  permanent  one.  Retardation  is 
usually  accompanied  by  alterations  in  the  emotional  back- 
ground which  exert  some  influence  over  the  function  of 
imagination  even  in  normal  life.  In  it  one  finds  that  the 
elaboration  of  external  impressions  is   rendered  difficult; 


DISTURBANCES  OF  MENTAL  ELABORATION  45 

indeed,  it  may  even  be  so  much  impaired  as  to  cause  com- 
plete perplexity,  owing  to  the  lack  of  memory  pictures; 
the  patients  cannot  think  of  anything,  they  lose  all  connec- 
tion with  their  earlier  experience,  and  sometimes  cannot 
even  give  the  names  of  their  nearest  relatives.  Nothing 
occurs  to  them.  Thought  seems  to  come  to  a  standstill. 
Such  patients  may  present  the  external  appearance  of  pro- 
found dementia ;  but  the  fact  that  all  of  these  severe  dis- 
turbances suddenly  disappear  indicates  retardation,  more- 
over the  patients  suffering  with  retardation  themselves 
recognize  the  resistance  against  which  they  have  to  struggle. 
They  are  not  stupid  or  indifferent  as  demented  patients 
are;  they  are  simply  unable,  in  spite  of  great  effort,  to 
overcome  the  constraint  of  thought. 

In  the  indifference  so  characteristic  of  dementia  prsecox 
there  is  no  resistance  offered  to  the  activity  of  thought, 
but  there  is  a  more  or  less  complete  lack  of  motive  for 
mental  work.  If  these  patients  are  sufficiently  stimulated, 
they  are  able  to  call  up  some  of  their  favorite  ideas,  but 
they  are  never  forced  to  mental  work  of  their  own  accord. 
They  take  no  account  of  what  happens  to  them,  and  they 
have  no  thought  of  the  future.  Mental  activity  stagnates 
more  and  more,  and  there  gradually  develops  a  shrinking 
of  the  store  of  ideas — a  sort  of  atrophy  from  disuse.  In 
contrast  to  the  paretic  they  often  surprise  one  by  the  oc- 
casional display  of  a  much  greater  wealth  of  ideas  than 
it  was  supposed  they  actually  possessed.  This  very  rarely 
happens  in  the  deteriorated  stages  of  dementia  paralytica. 
This  observation  confirms  the  belief  that  in  dementia 
praecox  there  is  a  real  loss  of  mental  activity. 

Morbid  excitation  of  the  imagination  is  evidenced  by  a 
special  vividness  of  the  memory  images,  which  under  cer- 
tain  circumstances   acquire   the   strength   of  sensory  im- 


46  GENERAL   SYMPTOMATOLOGY 

pressions.  This  occurs  particularly  in  the  different  delirious 
states,  where  there  is  almost  always  present  a  pronounced 
disturbance  of  apprehension.  Another  example  is  found  in 
some  of  the  anxious  states  of  melancholia,  manic-depressive 
insanity,  and  of  the  psychopathic  states,  in  which  the 
patients  detail  their  fears  with  painstaking  clearness  and 
completeness. 

In  the  excited  stages  of  manic  phases  of  manic-depres- 
sive insanity,  of  paresis  and  of  catatonia,  it  is  a  question 
whether  there  really  is  an  increase  of  the  imaginative 
power.  One  might  judge  that  there  was  no  question  as 
to  this  in  the  manic  phases  of  manic-depressive  insanity, 
but  really  the  realm  of  ideas  here  is  barely,  if  at  all,  enlarged, 
while  it  very  often  is  even  diminished.  Some  of  these 
patients  assert  that  they  abound  in  ideas,  and  even  in  the 
circular  depressive  phases  patients  may  make  the  same 
assertion,  in  spite  of  retardation.  There  is,  however,  good 
reason  to  believe  that  there  really  exists  more  of  an  in- 
creased distract ibility  and  Mightiness  of  the  internal 
processes  than  an  increased  production  of  ideas. 

A  persistent  increase  in  the  activity  of  the  imagination 
is  found  in  a  considerable  group  of  psychopathic  individuals, 
such  as  the  morbid  adventurer  and  inventor,  who  in  the 
pursuit  of  their  extravagant  plans  completely  lose  sight  of 
the  realities  of  life,  keeping  their  gaze  fixed  only  upon  the 
results,  while  they  never  take  into  serious  consideration  the 
difficulties  and  insufficiencies  of  their  methods.  Then  there 
is  the  dreamer,  who  gives  himself  up  to  reveries.  Finally 
there  are  the  morbid  liar  and  swindler,  who  take  the  greatest 
satisfaction  in  the  variegated  pictures  of  their  busy  imagina- 
tion. 

Great  activity  of  the  imagination  regularly  accompanies 
an  increased  susceptibility  of  thought  to  external  and  inter- 


DISTURBANCES  OF  MENTAL  ELABORATION  47 

nal  causes.  In  normal  individuals  this  trait  is  exhibited 
in  children  and  women.  Morbid  suggestibility  and  suscep- 
tibility to  autosuggestion  are  regular  accompaniments  of 
many  psychopathic  states,  especially  the  hysterical  condi- 
tions. They  are  manifest  here  not  only  in  the  accessibility  of 
thought  and  feeling  to  striking  impressions  and  persuasion, 
but  also  in  the  appearance  of  all  kinds  of  physical  symp- 
toms which  are  released  through  the  medium  of  emotional 
states. 

Disturbances  of  Judgment  and  Reasoning. — Judgment 
and  inference  are  the  most  complex  products  of  the  intellect. 
Since  perception,  memory,  the  formation  of  concepts,  and 
the  association  of  ideas  are  their  necessary  preconditions, 
they  will  be  more  or  less  affected  by  every  imperfection  of 
these  processes.  But  this  is  not  the  only  source  of  their 
derangement. 

Human  knowledge  has  two  sources :  experience,  and  the 
free  action  of  the  mind  itself  (imagination).  Neither 
source  is  entirely  independent  of  the  other;  empirical 
knowledge  is  never  free  from  preconception  and  expecta- 
tion, while  even  the  wildest  imagination  employs  material 
which  originally  came  from  experience.  Nevertheless,  we 
sharply  differentiate  empirical  knowledge  from  pure  belief, 
which  arises  from  the  recasting  and  interpretation  of 
experience. 

Primitive  people  do  not  draw  this  distinction.  Their 
mythological  interpretations  and  traditions  are  as  credible 
to  them  as  direct  experience.  Even  in  children  invention 
and  experience  are  sometimes  only  partially  differentiated. 
Whenever  invention  can  be  easily  tested  by  direct  experi- 
ence the  line  between  the  two  becomes  more  and  more 
sharply  defined;  but  even  here  the  natural  incompleteness 
of  our  apprehension  or  our  habits  of  thought  may  lead  us 


48  GENERAL  SYMPTOMATOLOGY 

into  error.  If  the  data  furnished  by  experience  is  scanty 
or  unreliable,  imagination  is  free  to  fill  the  field  with  its 
own  creations. 

Empirical  science  has  slowly  supplanted  many  of  the 
misconceptions  of  primitive  thought,  but  superstition  still 
survives  among  the  uncultured;  while  even  among  the 
cultured  there  are  beliefs  which  no  experience  or  arguments 
can  shake.  The  essential  characteristic  of  these  beliefs 
is  their  emotional  significance  for  the  individual.  Dog- 
matic opinions,  ideas  firmly  fixed  by  tradition,  education, 
and  habit,  acquire  an  overwhelming  emotional  value,  and 
not  only  persist  in  spite  of  experience,  but  even  mould 
experience  into  conformity  with  themselves  (cf.  the  force 
of  prejudice).  The  emotional  significance  of  such  beliefs 
has  its  basis  in  their  relation  to  vital  interest.  A  feeling 
of  helpless  dependence  and  insecurity  in  the  presence  of  the 
unknown  and  mysterious  is  the  fertile  soil  of  superstition 
in  primitive  races.  Even  in  most  highly  cultured  persons 
political  and  religious  convictions,  although  more  or  less 
dependent  on  the  rational  elaboration  of  experience  for 
their  content,  are  characteristically  inaccessible  to  opposi- 
tion and  argument. 

These  peculiarities  of  normal  thought  help  us  to  under- 
stand the  delusions  of  diseased  consciousness.  Delusions 
are  morbidly  falsified  beliefs  which  cannot  be  corrected  either 
by  argument  or  experience.  They  do  not  arise  from 
experience  or  deliberation,  but  from  belief.  Although 
often  associated  with  actual  and  falsified  perceptions  (hal- 
lucinations or  illusions),  they  are  always  due  to  a  morbid 
interpretation  of  the  events  arising  in  the  patient's  own 
imagination.  The  tendency  so  often  encountered  in  health, 
to  draw  sweeping  conclusions  from  insufficient  data  or  to 
assume  a  causal  relationship  between  purely  accidental 


DISTURBANCES  OF  MENTAL  ELABORATION  49 

occurrences,  becomes  an  important  factor  in  morbid  condi- 
tions; the  most  innocent  events  are  construed  as  mystic 
symbols  of  secret  occurrences,  and  simplest  facts  are  full  of 
mystery.  The  flight  of  a  bird  is  an  omen  of  good  fortune; 
an  accidental  gesture  reveals  sudden  danger. 

Further  proof  of  the  subjective  origin  of  delusions  is 
found  in  the  close  relation  which  they  maintain  to  the 
ego  of  the  patient.  Just  as  in  health  the  self  forms  the 
point  of  reference  for  our  thoughts  and  feelings,  so  in  disease 
the  mysterious  creations  of  the  imagination  are  most  in- 
timately connected  with  the  patient's  own  welfare.  The 
delusions  are,  consequently,  never  indifferent  to  the  patient 
except  in  cases  of  advanced  deterioration.  They  are  not 
only  referred  to  the  self,  but  they  exercise  a  marked  influence 
over  the  patient's  emotional  attitude  toward  his  environment. 

Delusions  are  inaccessible  to  argument,  because  they  do 
not  originate  in  experience.  Experience,  therefore,  is  un- 
able to  correct  them  as  long  as  they  remain  delusions. 
Only  in  convalescence,  when  they  become  a  mere  memory 
of  delusions,  can  they  be  recognized  as  false.  At  the  height 
of  the  disease  they  are  as  firmly  established  as  reason  herself. 
So  long  as  the  morbid  conditions  which  give  rise  to  them 
persist,  the  delusions  are  unchanged.  If  they  are  relin- 
quished or  modified,  the  change  is  not  due  to  argument, 
but  to  a  change  in  the  morbid  condition.  Our  argument 
may  drive  the  patient  to  admit  non-essential  points,  but 
the  delusion  serenely  reasserts  itself,  notwithstanding  the 
most  evident  self-contradiction.  Even  when  the  exter- 
nal object  of  reference  or  support  is  destroyed,  a  new  one 
is  quickly  found.  The  delusion  needs  no  other  support  than 
the  absolute  conviction  of  the  deluded. 

Vivid  emotional  states,  such  as  fear,  sorrow,  anger,  joy, 
and  enthusiasm   are  important  factors  in  the  origin  of 


50  GENERAL   SYMPTOMATOLOGY 

delusions.  Even  in  health,  anxiety  and  enthusiasm  create 
for  us,  in  the  consideration  of  any  subject,  fears  and 
hopes  which  really  have  nothing  to  do  with  the  subject 
matter.  In  morbid  conditions,  sorrow  and  fear  exert  the 
strongest  influence  on  the  falsifications  of  ideas. 

Clouding  of  consciousness  is  sometimes  a  factor  in  the 
development  of  delusions,  especially  in  delirious  states. 
Delirium  tremens  and  fever  delirium,  for  instance,  pre- 
sent a  host  of  fantastic  delusions  with  but  very  little  emo- 
tional disturbance.  Moreover,  delusions  which  are  firmly 
believed  one  day  may  be  recognized  as  false  the  next, 
clearly  indicating  a  morbid  condition  of  consciousness, 
which  rendered  their  correction  impossible.  We  have  an 
example  of  this  in  dreams,  where  we  are  unable  to  detect 
or  correct  those  contradictions  which  are  perfectly  clear 
to  us  on  awakening.  Without  doubt,  therefore,  we  must 
regard  the  clouding  of  consciousness  as  an  essential  pre- 
liminary condition  for  the  development  of  delusions. 

In  paresis,  senile  dementia,  and  dementia  prsecox,  delu- 
sions appear  in  which  neither  emotions  nor  disturbances  of 
consciousness  play  a  prominent  role.  The  psychic  weak- 
ness, which  is  a  prominent  symptom  in  these  diseases, 
seems  to  favor  the  development  of  delusions.  But  con- 
genital mental  weakness  shows  only  a  slight  tendency 
to  the  development  of  delusions,  and  likewise  many  cases 
of  senile,  paralytic,  and  precocious  dementia  run  their 
course  without  delusions.  The  real  cause  for  the  delusions 
cannot,  therefore,  lie  in  the  psychic  weakness  of  itself, 
but  only  in  the  accompanying  conditions  of  excitation, 
which  permit  all  sorts  of  delusional  fancies  to  spring  up  in 
the  patient's  mind.  It  can  be  easily  demonstrated  that 
delusions  originate  most  freely  during  heightened  or  de- 
pressed moods. 


DISTURBANCES  OF  MENTAL  ELABORATION  51 

Another  source  of  delusions  may  perhaps  be  found  in 
those  peculiar  ideas  which  in  health  are  accustomed  to 
occasionally  "pop"  into  our  heads,  and  whose  origin  we 
are  unable  to  account  for.  While  they  have  no  power 
over  us,  for  the  patient,  on  the  other  hand,  they  bear  the 
stamp  of  absolute  certainty,  even  though  soon  changed 
for  others.  They  often  intrench  themselves  firmly  in 
his  thoughts  and  dominate  experience,  feeling,  and 
conduct. 

After  this  preliminary  consideration  of  all  the  facts 
relative  to  the  origin  of  delusions,  we  are  led  to  the  as- 
sumption that  the  essential  factor  is  an  inadequate  func- 
tioning of  judgment  and  reason.  In  health  we  are  accustomed 
to  judge  all  our  fancies  according  to  the  standard  of  our 
own  past  experience,  and  to  regard  as  invention  that  which 
does  not  conform  to  our  knowledge.  The  patient  either 
does  not  perceive  the  contradictions  between  his  fancies 
and  his  former  experience,  or  he  disregards  it  and  hides  it 
under  assumptions  which  are  even  more  fanciful.  Clearly 
the  patient  has  lost,  not  only  the  impulse,  but  the  power, 
to  oppose,  correct,  or  suppress  his  delusions.  The  cause 
of  this  disability  was  formerly  sought  in  the  peculiar  at- 
tributes of  the  individual  ideas.  The  doctrine  of  " mono- 
mania," which  held  that  the  "fixed  idea"  was  only  a 
circumscribed  disturbance  of  an  otherwise  healthy  psychic 
life,  was  based  upon  this  assumption. 

The  development  of  delusions  is  thus  seen  to  be  based 
on  the  general  disturbance  of  the  entire  psychic  life.  They 
are  probably  incited  by  emotional  fluctuations  which  trans- 
form slumbering  hopes  and  fears  into  imaginary  ideas. 
But  the  fact  that  these  ideas  become  delusions  and  acquire 
a  power  which  even  the  senses  cannot  destroy,  can  only  be 
explained  by  an  inadequate  functioning  of  judgment,  depend- 


52  GENERAL  SYMPTOMATOLOGY 

ent  on  impassioned  emotional  excitement,  clouding  of  con- 
sciousness, and  weakness  of  the  reasoning  power. 

The  character  and  duration  of  delusions  differ  accord- 
ing to  their  mode  of  origin.  Those  which  originate  in 
emotional  disturbances  change  with  the  patient's  mood, 
and  usually  disappear  with  the  emotional  disturbance. 
Delusions  of  delirium,  which  are  determined  both  by 
clouding  of  consciousness  and  emotional  disturbances,  are 
variegated  fantastic  pictures  recurring  in  manifold  forms, 
with  little  or  no  mental  elaboration  or  coherence.  They 
likewise  disappear  with  the  clearing  of  consciousness  and 
the  subsidence  of  the  emotional  disturbance.  Delusions  de- 
pending both  upon  mental  deterioration  and  upon  emotional 
disturbances  do  not  vanish  with  the  fading  of  the  emotional 
states.  They  are  gradually  forgotten,  but  are  never  cor- 
rected by  reason.  Such  delusions  occur  in  paresis,  dementia 
praecox,  and  senile  dementia.  In  these  psychoses  the 
forgotten  delusions  may  reappear  for  short  periods  dur- 
ing emotional  exacerbations.  With  continued  moderate 
emotional  excitement  delusions  may  be  firmly  held  and 
even  elaborated,  as  in  the  paranoid  forms  of  dementia 
prsecox. 

Persistent  delusions  are  of  two  types,  the  systematized 
and  the  unsystematized.  If  systematized,  the  individual 
delusions  form  a  part  of  a  system  ;  i.e.  they  all  center 
about  some  one  or  more  definite  objects,  and  whenever  new 
delusions  develop  they  are  absorbed  into  this  system. 
Such  delusions  are  usually  expressed  in  a  logical  manner. 
The  unsystematized  delusions  may  ultimately  disappear, 
as  in  dementia  prsecox,  end  stages  of  chronic  alcohol- 
ism, paresis,  and  senile  psychoses,  or  they  may  become 
permanent  through  frequent  repetitions,  without  systemati- 
zation,  as  in  the  paranoid  form  of  dementia  praecox.    The 


DISTURBANCES   OF  MENTAL  ELABORATION  53 

progressive  and  uniform  systematization  of  the  delusions 
without  marked  mental  deterioration  constitutes  paranoia 
in  the  strict  sense  of  the  word.  In  this  form  the  delusions 
become  the  basis  of  a  thoroughly  elaborated,  but  falsified, 
apprehension  of  self  and  the  environment;  but  even  here 
a  decided  weakness  of  judgment  is  probably  always  de- 
monstrable. The  somewhat  similar  system  of  coherent 
delusions,  sometimes  found  in  paresis  and  dementia  prae- 
cox,  are  always  of  shorter  duration. 

Practically  all  delusions  center  in  the  self,  either  as 
self-depreciation  (depressive  delusions)  or  as  self-aggrandize- 
ment (expansive  delusions).  Among  depressive  delusions, 
those  of  self-accusation  stand  closest  to  the  normal  life. 
Many  normal  persons  torment  themselves  with  the  belief 
that  they  are  unlucky.  In  states  of  morbid  depression 
the  idea  of  guilt  may  be  associated  with  the  patient's 
every  action.  He  believes  that  he  is  constantly  injuring 
and  deceiving  others;  his  past  appears  to  him  as  a  series 
of  abominable  deeds  and  terrible  crimes.  He  is  an  irre- 
deemable, unfeeling  creature,  repudiated  by  God  and 
damned,  and  is  consequently  about  to  suffer  a  fitting 
punishment,  arrest,  the  scaffold,  the  stake,  or  whatever  else 
his  ingenuity  can  invent. 

Related  to  these  delusions  are  the  general  fears  of  pov- 
erty, loss  of  work,  or  some  other  misfortune  about  to  befall 
themselves  or  relatives.  In  progressing  mental  weakness 
this  form  of  delusions  may  become  nihilistic,  when  every- 
thing, the  patient  included,  is  non-existent  or  less  than 
nothing.  A  large  group  of  depressive  delusions  are  those 
of  persecution.  They  originate  during  periods  of  indispo- 
sition, discomfort,  or  anxiety.  Mistrust  and  suspicion  are 
excited  by  peculiar  coincidences  and  misinterpreted  re- 
marks.    Newspaper    articles    and    popular   songs    contain 


54  GENERAL  SYMPTOMATOLOGY 

references  and  even  indirect  insults.  All  assertions  of 
love  and  friendship  are  disbelieved.  At  this  time,  also, 
there  usually  appear  hallucinations,  especially  auditory. 
The  patient  sees  himself  involved  in  a  network  of  secret 
hostilities  and  imminent  dangers  which  he  cannot  escape. 
All  are  joined  against  him  and  gloat  over  his  misery.  Men 
call  after  him,  whisper  to  each  other,  shun  him,  spit  in  front 
of  him,  etc.  Food  and  drink  have  a  peculiar  taste,  as  if 
poisoned,  etc. 

Delusions  of  jealousy  also  play  a  prominent  role.  The 
patient  notices  a  coolness  in  marital  relations,  detects 
fond  glances  and  secret  signs,  finds  in  letters  arrange- 
ments for  secret  meetings.  The  wife  is  embarrassed  by 
his  unexpected  return  home,  tries  to  conceal  something, 
coughs  in  a  significant  manner,  the  room  is  darkened. 
Outside  some  one  pounds  on  the  door,  a  form  scurries  by 
the  window,  the  last  child  does  not  resemble  its  father, 
etc.  Indeed,  these  delusions  as  cited  by  the  patient  are 
sometimes  presented  with  such  good  foundation  that  it  is 
difficult  to  distinguish  them  from  ideas  of  infidelity  that  are 
actually  justified.  Delusions  of  infidelity  occur  principally 
in  chronic  alcoholism  and  cocainism,  but  also  in  senile 
mental  disorder. 

In  advanced  mental  weakness  the  persecutory  ideas 
often  assume  a  very  fantastic  form.  Absurd  somatic  delu- 
sions of  transformation  and  witchery,  such  as  telepathy, 
magical,  electrical,  or  hypnotic  influences,  are  common 
forms.  Sexual  delusions  are  especially  common,  varying 
from  mysterious  sexual  excitation  to  imagined  childbirth 
during  stupor.  All  these  evils  may  be  attributed  to  any 
individual  or  group  of  individuals  from  the  neighbor  or 
husband,  to  fraternal  or  political  societies. 

In  hypochondriacal  delusions  the  object  is  some  alleged 


DISTURBANCES  OF  MENTAL  ELABORATION  55 

incurable  disease.  Harmless  physical  symptoms  are  re- 
garded as  signs  of  syphilis,  sexual  excess,  paresis,  etc. 
With  the  onset  of  deterioration  the  delusions  become 
absurd  and  fantastic. 

Expansive  ideas  may  also  be  referred  to  a  somatic  basis. 
Thus,  feeble  paretics  extol  their  beautiful  voice,  their  gym- 
nastic dexterity,  although  they  cannot  produce  a  single 
musical  tone  or  even  stand  on  their  feet.  Closely  con- 
nected with  the  hypochondriacal  ideas  are  such  expansive 
ideas  as  that  the  excretions  are  gold,  Rhine  wine,  etc. 
Sometimes  delusions  with  a  depressive  content  acquire  the 
significance  of  expansive  ideas.  Patients  state  that  they 
will  die  at  once  in  order  to  be  translated  to  heaven ;  they 
send  invitations  to  their  own  execution,  which  is  to  be  con- 
ducted with  great  pomp. 

The  delusion  of  mental  soundness,  in  spite  of  deep-seated 
mental  disease,  constitutes  an  absence  of  insight  into  the 
disease.  This  absence  of  insight  is  almost  universal  in 
morbid  states ;  many  patients  not  only  consider  themselves 
perfectly  sane,  but  remarkably  intelligent,  as  in  paresis 
and  paranoia.  The  external  relations  of  the  patients,  the 
social  position  and  property,  are  similarly  transformed  by 
expansive  delusions.  Noble  descent,  close  relation  to  the 
temporal  and  spiritual  authorities,  even  association  with 
supernatural  powers,  are  among  the  most  frequent  forms. 
With  further  development  the  patient  becomes  the  Presi- 
dent, the  Pope,  Christ,  or  God.  On  the  other  hand,  patients 
boast  of  their  untold  wealth  and  vast  estates,  including 
whole  continents  or  the  world  itself,  while  vague  plans  of 
gigantic  undertakings  fill  their  minds. 

Depressive  and  expansive  delusions  are  by  no  means 
mutually  exclusive.  They  may  co-exist  or  follow  one 
another  very  closely.     The  victim  of  persecutory  delusions 


56  GENERAL  SYMPTOMATOLOGY 

discovers  an  adequate  cause  of  this  persecution  in  ex- 
ceptional ability,  natural  right  to  great  possession  or 
high  positions.  His  detention  is  the  result  of  jealousy  or 
intrigues.  These  relations  are  not  the  result  of  logical 
elaboration,  but  rather  spontaneous  and  independent  con- 
sequences of  the  internal  condition  of  the  patient.  In 
dementia  praecox  the  appearance  of  expansive  ideas  follow- 
ing delusions  of  persecution  indicates  a  decided  progress 
of  mental  weakness. 

Disturbances  of  the  Rapidity  of  Thought.  —  The  normal 
rapidity  of  the  association  of  ideas  and  concepts  varies  so 
greatly  in  different  individuals,  and  sometimes  even  in  the 
same  individual,  that  it  has  been  impossible  to  establish  a 
standard  by  which  morbid  deviations  can  be  accurately  esti- 
mated. We  are,  however,  able  to  recognize  two  disturbances ; 
namely,  retardation  and  acceleration  of  the  train  of  thought. 

Retardation  occurs  even  in  healthy  individuals  as  the 
result  of  physical  and  mental  fatigue.  Some  unpleasant 
emotional  states  produce  the  same  result.  It  also  occurs 
during  the  intoxication  produced  by  alcohol,  ether,  chloro- 
form, chloral,  and  to  a  moderate  degree  after  the  use  of 
tobacco.  This  disturbance  is  characteristic  of  the  depres- 
sive and  mixed  forms  of  manic-depressive  insanity,  is 
found  in  the  end  stages  of  dementia  prsecox  and  paresis, 
and  in  congenital  imbecility.  Moderate  retardation  ap- 
pears also  in  melancholia. 

Acceleration  is  less  frequent  than  retardation.  In  nor- 
mal life  it  is  produced  only  by  some  forms  of  emotional 
excitement,  and  by  such  drugs  as  morphine,  caffeine,  and 
ethereal  oil  of  tea.  In  morbid  states  genuine  acceleration 
is  probably  never  found.  In  flight  of  ideas  the  thought 
may  appear  accelerated,  but  even  here  real  delay  can  usu- 
ally be  demonstrated. 


DISTURBANCES  OF  MENTAL  ELABORATION  57 

Disturbances  of  Capacity  for  Mental  Work.  —  The  capac- 
ity for  mental  work  is  independent  of  the  rapidity  of 
thought.  It  is  scarcely  to  be  measured  by  direct  experi- 
mentation, although  it  forms  a  most  important  symptom 
of  mental  disease.  In  normal  life  the  capacity  for  mental 
work  is  determined  by  the  residua  of  past  efforts.  These 
residua  condition  the  increase  of  capacity,  which  we  call 
practice.  In  morbid  states  the  effects  of  practice  are 
usually  lessened  and  rapidly  disappear,  particularly  in 
congenital  imbecility. 

The  capacity  for  mental  work  stands  in  inverse  ratio  to 
susceptibility  to  fatigue.  Increased  susceptibility  to  fatigue 
is  very  general  in  most  forms  of  insanity.  We  find  it  in 
exhaustion  psychoses,  dementia  prsecox,  congenital  imbe- 
cility, and  paresis,  where  it  is  often  the  first  striking 
symptom  of  the  disease.  In  neurasthenia  it  is  often 
masked  by  increased  nervous  irritability. 

Recovery  from  fatigue  is  effected  by  relaxation  and 
especially  by  sleep.  Melancholiacs  and  neurastheniacs 
recover  very  slowly  from  the  effects  of  mental,  emotional, 
and  physical  activity.  This  is  the  result,  in  part  of  dis- 
eased mental  tone,  in  part  also  it  results  from  disturb- 
ances of  sleep,  not  only  in  amount  but  depth.  It  has 
been  shown  that  in  conditions  of  simple  overwork  the  sleep 
is  light,  attains  its  greatest  depth  very  slowly,  and  shows 
an  incomplete  abatement  of  its  profoundness  in  the  morn- 
ing. 

Finally  the  capacity  for  work  is  markedly  decreased  by 
distractibility .  It  can  arise  from  insufficient  intensity  of 
the  goal  ideas,  from  unusual  vividness  of  individual  pres- 
entations, or  finally  from  an  increased  susceptibility  to 
distracting  influences.  Inadequacy  of  the  goal  ideas  is 
probably  the  cause  of  distractibility  in  paresis  and  dementia 


58  GENERAL  SYMPTOMATOLOGY 

praecox.  The  vividness  of  individual  presentations  is  seen 
in  the  distractibility  of  acute  exhaustion  psychoses,  and 
especially  in  manic-depressive  insanity,  and  probably  also 
in  excited  periods  of  dementia  praecox  and  paresis.  The 
increased  susceptibility  to  distracting  influences  is  a  regu- 
lar symptom  of  neurasthenia,  where  quite  insignificant 
forms  of  irritation  may  become  altogether  intolerable. 

Disturbances  of  Self-consciousness.  —  The  sum  total  of 
all  those  presentations  which  form  the  complex  idea  of 
our  physical  and  mental  personality  constitutes  self- 
consciousness.  This  is  the  permanent  background  of  our 
mental  life,  and  exercises  a  characteristic  influence  on  the 
course  of  all  our  mental  processes.  In  content  as  well  as 
scope,  self-consciousness  is  determined  by  the  experiences  of 
each  individual.  It  is  a  familiar  phenomenon  in  dreams 
that  one  may  carry  on  a  complete  dialogue ;  indeed,  one 
may  be  completely  taken  back  by  some  particularly  strik- 
ing expression  of  his  interlocutor.  Apparently  in  such 
cases  the  unity  of  self-consciousness  is  lost,  which  in  the 
waking  state  permits  us  to  oversee  all  our  thoughts  and 
inner  impulses  at  once.  Such  a  dual  personality  or  splitting 
of  self-consciousness  often  occurs  in  mental  disease.  Possi- 
bly the  first  indications  of  this  are  found  in  those  cases  in 
which  sense  deceptions  appear  to  the  patients  as  strange 
phenomena  of  external  origin.  Whenever  a  patient  suffer- 
ing from  delirium  tremens  overhears  some  derisive  dialogue 
about  himself,  or  plans  of  a  threatening  nature  being  de- 
vised against  him,  there  is  no  doubt  in  his  mind  that 
these  are  of  external  origin  and  not  the  hallucinatory 
expressions  of  his  own  thoughts  and  fears.  Unbeknown  to 
himself  he  plays  the  role  of  two  different  persons.  Splitting 
of  self-consciousness  is  often  observed  in  dementia  praecox, 
where  the  patients  refer  to  foreign  influences  and  enemies 


DISTURBANCES  OF  MENTAL  ELABORATION  59 

residing  within  their  bodies,  the  thoughts  and  actions  of 
which  they  differentiate  very  clearly  from  their  own.  Some 
hysterical  symptoms  may  be  similarly  explained. 

The  temporal  connections  of  one's  personality  with  the 
past  may  be  disordered  in  such  a  way  that  the  memory  of 
certain  periods  of  life  of  longer  or  shorter  duration  are  com- 
pletely lost.  If  during  any  such  period  of  life  there  has 
been  no  development,  self-consciousness  remains  on  the 
same  plane  that  it  was  at  the  beginning  of  the  period ;  in 
this  case  the  interval  is  bridged  over  by  means  of  falsifica- 
tions of  memory  or  inferences.  The  patient  depends  upon 
inferences  in  the  interruptions  in  self-consciousness  occur- 
ring in  clouding  of  consciousness,  sleep,  fainting,  befogged 
states,  and  delirious  conditions,  and  on  fabrications  in 
Korssakow's  psychosis  where  loss  of  memory  is  produced 
by  disorder  of  the  attention.  The  so-called  condition  of 
"  double  consciousness  "  represents  another  form  of  dis- 
turbed self-consciousness  where  there  is  a  more  or  less  reg- 
ular alternation  of  different  states  in  each  of  which  there  is 
memory  only  for  the  experiences  of  similar  previous  states. 
Thus  two  different  personalities  are  dovetailed,  each  of 
which  has  at  its  disposal  only  a  part  of  the  total  experience 
of  the  individual.  As  a  rule,  one  of  these  personalities 
belongs  to  an  earlier  stage  of  development  than  the  other, 
and  consequently  does  not  possess  all  the  skill  and  knowl- 
edge that  the  other  commands.  Sometimes  there  takes 
place  a  reversion  to  a  particular  period  of  the  individual's 
past  life,  which  has  been  conspicuous  because  of  certain  ex- 
periences. This  condition,  called  ekmnesia  by  the  French, 
may  be  induced  experimentally  by  hypnosis,  and  is  charac- 
teristic more  especially  of  hysterical  insanity. 

Self-consciousness  is  no  fixed  mental  construct,  but  it 
changes  continuously  with  experience.    So  disease  processes 


60  GENERAL  SYMPTOMATOLOGY 

are  able  to  falsify  it,  though  not  in  like  manner.  The 
cause  of  this  is  not  clear.  The  alteration  of  self-conscious- 
ness in  the  depressive  stages  of  manic-depressive  insanity 
is  often  very  striking,  while  in  melancholia  it  may  be 
insignificant  in  spite  of  the  extensive  delusional  conception 
of  the  environment.  Also  in  delirium  tremens  the  patients 
have  the  most  fantastic  experiences  without  suffering  any 
alteration  of  self-consciousness.  Since  the  most  extensive 
alterations  of  self-consciousness  occur  in  paresis,  dementia 
prsecox,  and  in  manic-depressive  insanity,  the  hypothesis 
is  plausible  that  this  disease  symptom  is  related  to  dis- 
turbances of  will.  On  the  other  hand,  we  are  accustomed 
to  ascribe  disturbances  of  the  will  in  large  measure  to  the 
character  of  the  psychic  personality. 

The  particular  form  of  the  falsification  of  self -conscious- 
ness is  determined  by  the  morbid  disposition.  Thus  in 
manic  patients  the  peculiar  condition  of  self-consciousness 
leads  to  the  development  of  expansive  ideas,  which  in  reality 
are  nothing  more  than  a  playful  expression  of  the  emotional 
elation.  In  the  depressive  and  stuporous  phases  of  manic- 
depressive  insanity  the  patients  become  not  only  depressed 
and  abject,  but  they  even  feel  physically  altered  —  turned 
to  stone,  dead,  and  transformed  into  other  individuals, 
such  as  the  devil  and  animals.  Similarly  the  paretic  in 
accord  with  his  expansive  and  pessimistic  ideas  comes  to 
believe  that  his  body  is  variously  altered.  In  dementia 
praecox  this  condition,  although  present,  is  less  pronounced, 
and  in  contrast  to  paresis  and  manic  depressive  insanity  is 
not  infrequently  associated  with  ideas  of  some  sort  of  exter- 
nal influence  which  produces  the  alteration.  In  paranoia, 
the  disturbance  of  self-consciousness  is  very  slight  and  con- 
fined to  the  delusional  overestimation  of  the  patient's 
abilities. 


DISTURBANCES  OF  MENTAL  ELABORATION  61 

In  advanced  deterioration,  self-consciousness  ultimately 
disappears.  In  dementia  prsecox  and  paresis  this  is  the 
usual  terminus  of  the  mental  life.  It  is  to  be  especially 
emphasized,  however,  that  this  is  not  the  result  of  deterio- 
ration, but  a  special  symptom  of  these  diseases.  In  some 
cases,  on  the  other  hand,  even  when  the  store  of  ideas  is 
much  impoverished,  the  patient  still  retains  his  self-con- 
sciousness and  can  give  an  account  of  his  own  condition. 
This  is  particularly  common  in  epileptics.  Even  in  pres- 
byophrenia, where,  on  account  of  the  marked  disturbance 
of  attention,  experiences  disappear  entirely  from  memory 
and  are  replaced  by  the  freest  invention,  self -consciousness 
is  retained. 


0.   DISTURBANCES   OF  THE  EMOTIONS 

Every  sensory  impression  which  sustains  any  intimate  re- 
lation to  man's  welfare  is  accentuated  in  consciousness  by 
a  concurrent  feeling  of  pleasure  or  pain,  depending  on  its 
apparent  tendency  to  advance  or  retard  the  general  aims  of 
life.  Therefore,  the  feelings  are  a  direct  indication  of  the 
attitude  of  the  ego  to  the  perceptions  of  the  external  world. 
According  to  Wundt,  one  can  distinguish  three  opposite 
states  of  feeling,  which  rarely  exist  alone,  but  almost  always 
accompany  mental  processes  in  various  combinations; 
namely,  pleasure  and  displeasure,  excitement  and  calmness, 
perhaps  preferably  retardation,  and  finally  tension  and 
relaxation.  Disturbances  of  the  emotional  life  often  form 
the  first  striking  symptom  of  disease.  But  the  recognition 
and  estimation  of  these  disturbances  is  difficult,  because 
we  lack  an  adequate  normal  standard.  Even  in  health  the 
emotions  show  marked  personal  peculiarities,  closely  allied 
to  the  abnormal. 

Diminution  and  Increase  of  Emotional  Irritability.  —  The 
diminution  of  the  intensity  of  the  emotions  is  their  simplest 
and  most  frequent  disturbance.  In  normal  life  one's  interest 
in  the  environment  is  reflected  in  more  or  less  intense  fluc- 
tuations of  his  emotions.  Diminution  of  these  emotional 
accentuations  indicate  indifference  toward  the  impressions 
of  the  external  world.  This  is  characteristic  of  most  forms 
of  mental  deterioration,  of  which  it  is  one  of  the  first  and 
most  striking  symptoms.  Emotional  indifference  may  be 
marked  even  when  external  impressions  are  well  apprehended 

62 


DISTURBANCES  OF  THE  EMOTIONS  63 

and  elaborated.  This  striking  disproportion  between  dis- 
turbances of  the  intellect  and  the  emotions  is  most  pro- 
nounced in  dementia  prgecox.  In  paresis,  on  the  other  hand, 
mental  elaboration  is  disturbed  to  a  much  greater  degree 
than  the  emotions. 

All  phases  of  the  emotional  life  seldom  suffer  equally. 
Naturally  the  patient  loses  most  easily  those  feelings  which 
are  not  directly  connected  with  the  changes  of  his  own  ego, 
but  are  related  to  the  more  remote,  external  world,  and 
further  those  feelings  which  have  lost  their  sensory  proper- 
ties and  are  aroused  only  through  the  higher  mental  processes 
as  concomitants  of  general  ideas  and  moral  principles.  The 
active  interest  of  the  patient  becomes  exclusively  selfish. 
He  loses  all  pleasure  in  mental  work,  and  all  feeling  for  the 
higher  claims  of  propriety,  morality,  and  religion.  Considera- 
tion for  his  environment,  his  family,  relatives,  and  finally  for 
mankind  in  general,  has  no  influence  on  his  conduct.  He 
loses  the  sense  of  shame  and  lacks  all  comprehension  of  the 
conventions  of  social  intercourse. 

Emotional  deterioration  is  very  often  the  first  striking 
symptom  of  dementia  prsecox,  and  advances  with  the 
progress  of  the  disease.  It  regularly  occurs  in  senile  de- 
mentia, and  sometimes  is  an  early  symptom  of  paresis.  In 
its  simplest  form  it  appears,  also,  in  simple  senility.  Emo- 
tional deterioration  is  also  prominent  in  many  forms  of 
congenital  imbecility,  especially  the  so-called  "  moral  im- 
becility," in  which  the  patients  show  a  certain  shrewdness 
in  the  attainment  of  selfish  advantages  which  often  conceals 
the  real  severity  of  the  disease. 

Lower  or  sensuous  feelings  possess  a  greater  momentary 
intensity,  but  are  at  the  same  time  more  transitory  than 
the  higher  moral  aesthetic  sentiments,  which  accompany  and 
determine  our  thoughts  and  actions  throughout  our  entire 


64  GENERAL  SYMPTOMATOLOGY 

life,  and  act  as  checks  on  sudden  emotional  impulses  of  the 
lower  order. 

The  absence  of  these  checks  in  imbecility  gives  rise  to 
sudden,  but  transitory,  outbursts  of  passion.  Without  a 
firm  foundation  for  the  emotional  life  a  mere  trifle,  a  word, 
the  tone  of  the  voice,  suffices  to  plunge  the  patient  from  the 
most  blissful  self-complacency  into  the  most  profound  de- 
spair. This  is  an  especially  prominent  symptom  in  paresis. 
The  emotional  indifference  characteristic  of  the  end  stages 
of  dementia  praecox  is  regularly  accompanied  by  such  emo- 
tional ebullitions.  A  permanent  characteristic  of  emotional 
indifference  is  lack  of  insight.  The  retardation  of  depressed 
manic-depressive  patients  sometimes  presents  a  superficial 
similarity  to  the  emotional  indifference  of  the  deteriorated, 
but  the  former  realize  their  condition,  and  often  complain 
that  they  are  forsaken  and  desolate.  An  especial  vivacity 
of  the  emotions  is  characteristic  of  women  and  children. 
The  emotional  states  are  highly  unstable  and  are  readily 
influenced  by  momentary  conditions.  The  great  ease  with 
which  vivid  feelings  appear  and  disappear  is  characteristic 
of  some  of  the  psychopathic  states.  This  condition  under- 
lies the  syndrome  of  hysteria.  In  this  disease  ideas  have 
such  an  intense  emotional  tone  that  a  powerful  influence  is 
exerted  not  only  over  the  will  but  also  over  such  physical 
processes  as  are,  in  general,  not  under  voluntary  control; 
as,  breathing,  circulation,  pulse,  muscles  of  the  bladder, 
rectum,  and  hair,  secretions  of  the  glands,  as  well  as  the 
accuracy  of  movements  and  the  clearness  and  intensity  of 
sensations. 

A  temporary  increase  of  the  emotional  irritability  is  seen 
in  some  of  the  excited  stages  of  paresis,  catatonia,  and  in 
manic  phases  of  manic-depressive  insanity.  Since  the 
vividness   of   the   temporary   emotional  state   forces   the 


DISTURBANCES  OF  THE  EMOTIONS  65 

restraining  influence  of  the  higher  feeling  completely  into 
the  background,  this  condition  is  accompanied  by  the  im- 
portant phenomenon — change  of  mood.  A  similar  condi- 
tion is  observed  in  the  intoxicated  individual,  in  whom 
the  exuberance  of  feeling  is  so  often  accompanied  by 
abrupt  change  of  mood.  In  this  condition  it  is  possible 
for  one  to  influence  markedly  the  tone  of  feeling  of  the 
patient  except  in  catatonic  excitement,  where  negativism 
prevails. 

Morbid  Temperaments.  —  The  same  experience  may  arouse 
wholly  different  mental  attitudes  in  different  individuals, 
according  to  the  constitutional  tendency  to  certain  tones  of 
feeling,  the  temperament  of  the  individual.  Because  of  the 
infinite  variety  of  the  combinations  of  feelings  it  is  almost 
impossible  to  describe  all  the  different  types  of  tempera- 
ment. In  the  morbid  field  this  difficulty  is  even  greater; 
hence  we  must  content  ourselves  with  a  brief  sketch  of  only 
some  of  the  forms. 

Since  displeasure  exerts  in  general  a  stronger  influence 
over  our  mental  life  than  pleasure,  we  would  expect  to  find 
it  playing  the  more  prominent  role  in  morbid  states.  This 
increased  susceptibility  to  the  unpleasant  leads  to  a  tendency 
to  discover  in  all  of  life's  experiences  only  that  which  is 
unpleasant.  The  past  is  crowded  with  sad  experiences  and 
the  future  a  source  of  anxiety.  The  individual's  own  well- 
being  is  the  centre  of  his  thought,  and  every  insignificant 
ailment  is  regarded  as  a  sign  of  threatening  disease.  The 
dejection  which  in  normal  life  accompanies  sad  experiences 
gradually  wanes,  but  in  disease  even  a  cheerful  environ- 
ment fails  to  mitigate  sadness,  indeed,  it  may  even  in- 
tensify it. 

Whenever  morbid  sadness  is  accompanied  by  an  inner 
tension,  the  emotional  state  becomes  one  of  apprehensiveness. 


66  GENERAL  SYMPTOMATOLOGY 

The  patient  feels  a  lack  of  security  and  freedom,  together 
with  a  lack  of  confidence  in  his  own  ability.  He  awaits 
with  apprehension  the  outcome  of  every  act,  and  doubts  its 
justification  and  fitness.  In  this  state  his  own  physical 
condition  is  a  very  fruitful  source  for  the  development  of 
all  sorts  of  doubts.  There  develops  a  self-torture  and  an 
exaggerated  feeling  of  liability.  This  type  of  feeling  furnishes 
the  basis  for  the  morbid  fears  to  be  described  later,  and  also 
is  often  seen  in  the  incipient  stages  of  melancholia. 

When  this  increased  susceptibility  to  the  unpleasant  is 
associated  with  excitement,  there  exists  what  is  known  as 
an  irritable  disposition.  This  is  characterized  not  only  by  a 
general  tone  of  displeasure  toward  everything,  but  by  an 
emotional  excitement  which  demands  expression  and  is 
held  in  check  only  by  a  constant  struggle.  This  lack  of 
control  means  a  persistent  variation  of  the  emotional  equi- 
librium and  a  condition  of  instability  with  occasional  violent 
outbursts  of  feeling,  which  sometimes  take  the  form  of 
despair  and  sometimes  of  anger.  Despair  is  encountered 
chiefly  in  congenital  neurasthenia,  while  anger  is  found 
especially  in  the  epileptic  and  hysterical  constitutions 
(Irabundia  Morbosa). 

Morbid  sensitiveness  to  the  outer  world  does  not  always 
lead  to  passionate  outbreaks,  but  sometimes  produces  that 
type  of  temperament  termed  seclusiveness.  Seclusiveness  is 
not  accompanied  by  that  passionate  feeling  of  anger  that 
goes  with  the  defiance  of  a  normal  individual,  but  it  indi- 
cates a  sort  of  shrinking  from  the  impressions  of  life  with  a 
more  or  less  clear  consciousness  of  one's  own  insufficiency. 
Conversation  with  strangers,  entering  a  new  environment, 
unusual  demands,  and  difficulties  appear  to  a  patient  as 
unsurmountable  obstacles.  This  condition  underlies  the 
conduct  of  many  of  the  merely  "  peculiar  "  individuals.    A 


DISTURBANCES  OF  THE  EMOTIONS  67 

history  of  such  peculiarities  often  antedates  the  outset  of 
dementia  prsecox. 

The  pronounced  feelings  of  pleasure  are  found  in  those 
happy  sunny  dispositions  that  are  always  in  good  humor, 
see  things  on  the  best  side,  and  are  most  enthusiastic. 
Associated  with  this  state  there  is  often  a  pressure  of 
activity,  which  incites  the  individual  to  various  changing 
unsuccessful  pursuits;  a  combination  which  also  exists  in 
manic-depressive  insanity. 

Another  modification  of  the  emotional  life  is  fanaticism. 
Here  also  there  develops  prominently  types  of  feeling, 
especially  of  a  religious  and  sexual  nature,  which  control 
thought  and  action.  These  individuals  may  exhibit  the 
most  extraordinary  feeling  of  happiness  that  rises  above  all 
external  sadness  and  adversity.  The  hysterical  constitution 
arises  from  this  sort  of  a  basis.  Closely  related  to  these 
fanatics  are  the  morbid  swindlers  with  their  great  love  for 
adventure,  and  for  the  exciting  and  the  unusual.  The 
exaggerated  joy  in  their  own  inventiveness  forces  all  delib- 
eration into  the  background.  Hysterical  symptoms  also 
exist  here. 

A  closely  allied  disposition  is  morbid  frivolity,  charac- 
terized by  superficiality  of  the  emotions.  Here  there  is 
an  increased  susceptibility  to  superficial  distractions  while 
serious  things  are  not  taken  seriously.  Life  in  general  is 
regarded  as  a  joke.  Associated  with  this  morbid  frivolity, 
which  is  an  essential  element  in  some  forms  of  imbecility 
and  weakmindedness,  there  is  regularly  a  defective  develop- 
ment of  the  higher  feelings,  a  selfishness  and  instability  of 
the  will. 

A  common  characteristic  of  this  condition  of  frivolity  is  an 
exaggerated  self-consciousness.  The  patients'  own  abilities 
and  work  appear  to  them  in  an  especially  favorable  light. 


68  GENERAL  SYMPTOMATOLOGY 

These  patients  not  only  grossly  overestimate  themselves,  but 
have  a  corresponding  lack  of  sympathy  for  others.  This 
selfish  onesidedness  of  the  tone  of  feeling  exists  in  many 
born  criminals,  also  in  the  pseudo-querulants,  where  it  is 
combined  with  great  irritability.  It  is  probably  also  a 
favorable  soil  for  the  development  of  genuine  querulants 
and  perhaps  the  allied  forms  of  paranoia. 

Morbid  Emotions.  —  Morbid  emotions  are  distinguished 
from  healthy  emotions  chiefly  through  the  lack  of  a  suffi- 
cient cause,  as  well  as  by  their  intensity  and  persistence ; 
furthermore  the  tone  of  feeling  usually  corresponds  to  some 
of  the  well-known  mixed  feelings.  Even  in  normal  life 
moods  come  and  go  in  an  unaccountable  way,  but  we  are 
always  able  to  control  and  dispel  them,  while  morbid  moods 
defy  all  attempts  at  control.  Again,  morbid  emotions  some- 
times attach  themselves  to  some  certain  external  occasions, 
but  they  do  not  vanish  with  the  cause  like  normal  feelings, 
and  they  acquire  a  certain  independence. 

By  far  the  commonest  form  of  the  unpleasant  morbid 
emotions  is  fear,  which  may  perhaps  be  regarded  as  a  com- 
bination of  a  feeling  of  displeasure  with  an  inner  tension. 
It  influences  the  whole  physical  and  mental  condition  more 
profoundly  than  any  of  the  other  emotions.  The  inner 
tension  is  exhibited  physically  by  the  facial  expression, 
bodily  attitude,  convulsive  action  of  the  muscles,  in  a  moan 
or  an  outcry,  in  an  act  of  defence  or  escape,  in  attacks  on 
the  surroundings  or  the  patient's  own  life.  Besides  this 
there  is  apt  to  be  precordial  oppression,  palpitation,  pallor, 
increased  respiration,  tremor,  and  sometimes  perspiration 
and  an  increased  desire  to  urinate  and  defecate.  In  morbid 
conditions  fear  is  usually  without  an  object  at  first.  The 
patients  feel  afraid  without  knowing  why,  and  indeed  are 
often  well  aware  that  their  fears  are  groundless.     In  the 


DISTURBANCES  OF  THE  EMOTIONS  69 

constitutional  psychopathic  states  the  indefinite  fear  often 
assumes  peculiar  forms,  as  the  feeling  of  homesickness  and 
the  like.  In  acute  mental  disturbances  the  indefinite  anx- 
ious forebodings  become  fixed  into  more  or  less  definite 
fears.  Extreme  fear,  like  all  extreme  emotions,  is  always 
accompanied  by  a  clouding  of  consciousness. 

Fear  is  not  maintained  at  the  same  intensity  for  any 
considerable  length  of  time,  but  shows  remissions,  and 
aggravations,  the  latter  especially  at  night.  Fear  is  most 
pathognomonic  of  melancholia  of  involution,  where  it  is 
seldom  absent.  It  occurs  frequently  in  depressive  forms  of 
manic-depressive  insanity,  but  may  be  absent.  It  occurs 
also  in  the  befogged  states  of  epilepsy,  in  delirium  tremens, 
and  in  the  beginning  of  catatonic  excitement.  Paresis 
sometimes  presents  fear  in  its  most  extreme  form. 

A  large  group  of  disturbances  characterized  by  fear  is 
found  in  the  so-called  compulsive  fears,  phobias.  These  fears 
are  sometimes  associated  with  some  personal  experience  or 
idea  which  has  given  rise  at  some  time  to  fear.  In  the 
lightest  forms  such  fears  are  encountered  in  normal  in- 
dividuals, but  here  they  lack  the  persistency  and  obtrusive- 
ness  which  characterize  the  phobias. 

The  compulsive  fears  are  characteristic  of  some  forms  of 
the  psychopathic  states,  but  may  appear  transitorily  in 
manic-depressive  insanity.  These  compulsive  fears  include 
the  fear  at  the  sight  of  or  contact  with  certain  objects,  as 
spiders,  knives,  needles,  etc.;  also  the  fear  of  being  alone 
on  deserted  streets,  the  fear  of  crowded  rooms,  of  open  or 
closed  doors,  etc.  (see  pp.  499-503).  These  patients  are 
tormented  by  the  idea  that  their  clothes  do  not  fit  properly, 
that  they  themselves  are  soiled  or  poisoned  by  contact  with 
others,  that  they  might  have  swallowed  needles  or  fragments 
of  glass,  that  in  tearing  up  any  scrap  of  paper  they  might 


70  GENERAL  SYMPTOMATOLOGY 

have  destroyed  valuable  papers,  etc.  Other  closely  allied 
disturbances  are  the  feelings  of  discomfort  which  arise 
whenever  individuals  are  compelled  to  come  into  any  sort  of 
relations  with  others,  as  in  erythrophobia,  morbid  blushing. 

While  fear  has  been  designated  as  sadness  with  inner 
tension,  simple  dejection  is  defined  as  sadness  with  inhibi- 
tion ;  in  other  words,  anguish  with  a  feeling  of  insufficiency. 
The  basis  for  this  emotional  state  is  found  in  the  sorrow 
arising  in  the  person  himself,  which  impresses  itself  upon 
all  of  the  experiences  of  life.  As  the  result  of  this,  the 
entire  past  seems  but  a  series  of  misfortunes  and  failures; 
the  present  is  troubled  and  dark,  and  the  future  dubious; 
all  sorts  of  sad  thoughts  and  forebodings  arise,  which  may 
lead  to  delusional  ideas  of  self-reproach  and  persecution, 
but  the  most  painful  is  the  feeling  of  desolation.  Patients 
feel  neither  pleasure  nor  sorrow;  indeed,  they  do  not  re- 
spond emotionally  to  any  of  the  impressions  of  the  outer 
world.  One  patient  expressed  himself  by  saying  that  he 
felt  "  like  a  cinematograph.  To  be  sure  I  see  things  well 
enough,  but  I  don't  feel  them."  The  normal  pleasure  in 
mere  existence  gives  place  to  a  feeling  of  weariness  of  life. 

The  alteration  of  the  tone  of  feeling  which  is  characteristic 
of  some  of  the  circular  depressive  phases  of  manic-depressive 
insanity  as  a  rule  is  accompanied  by  a  retardation  of  thought 
and  action.  The  patients  regard  their  condition  as  the  most 
agonizing;  they  feel  as  if  they  were  inwardly  dead,  had 
become  heartless  and  morally  desolate.  They  frequently 
entertain  ideas  of  physical  alteration.  In  reality  these 
patients  are  not  without  feeling,  as  may  be  judged  from 
their  occasional  attempts  at  suicide.  The  retardation  may 
suddenly  give  place  to  excitement. 

Sadness  with  excitement  is  occasionally  observed  in  manic- 
depressive   insanity,    occurring   either  as   an   independent 


DISTURBANCES  OF  THE  EMOTIONS  71 

phase  or  as  a  transitional  stage  between  different  phases 
of  the  disease.  In  this  case  the  mood  is  sometimes  sad, 
sometimes  anxious  or  passionate,  the  patients  expressing 
themselves  in  wailing  and  moaning,  in  states  of  anxiety,  or 
in  outbreaks  of  irritability.  The  latter  form  is  particularly 
common.  The  patients  are  fretful,  discontented,  at  variance 
with  themselves  and  their  environment,  and  annoyed  by 
trifles.  They  grumble  and  growl  in  the  most  intolerable 
manner  and  show  outbursts  of  passion  on  the  slightest 
provocation.  An  emotional  state  of  this  sort  combined  with 
exaggerated  conceit  and  an  attempt  to  be  sarcastic  is 
sometimes  encountered  in  syphilitic  insanity.  Many  of  the 
emotional  states  of  the  hysterical  patient  exhibit  a  mixture 
of  sadness  and  excitement  with  passionate  irritability. 

The  epileptic  presents  a  special  type  of  emotional  dis- 
turbance ;  namely,  a  simple  dejection  with  a  feeling  of  weari- 
ness of  life.  Occasionally  it  is  associated  with  a  feeling  of 
inhibition,  but  usually  there  is  a  sort  of  homesick  feeling 
with  an  indefinite  yearning  and  inner  restlessness,  which 
leads  to  suicidal  attempts,  indulgence  in  alcohol,  or  aimless 
wandering.  Yet  irritability  with  sudden  violent  outbursts 
of  great  intensity  is  quite  common.  In  the  epileptic  be- 
fogged states  a  tense  anxious  feeling  predominates,  some- 
times combined  with  great  irritability.  Furthermore  in  all 
of  these  emotional  states  there  may  be  a  mixture  of  a  sexual 
or  ecstatic  feeling  of  pleasure. 

The  morbid  feelings  of  pleasure  are  less  frequent  than 
those  of  displeasure.  They  occur  especially  in  alcoholic 
intoxications  and  alcoholic  psychoses,  manic-depressive  in- 
sanity, paresis,  dementia  praecox,  morphin  and  cocain  intoxi- 
cation. The  feeling  of  increased  strength,  enthusiasm,  and 
enterprise  which  results  from  alcohol  probably  originates  in 
the  facilitation  of  the  release  of  motor  impulses  in  the  brain, 


72  GENERAL  SYMPTOMATOLOGY 

while  further  action  of  the  drug  causes  irritability,  restless- 
ness, and  aimless  activity.  In  the  manic  forms  of  manic- 
depressive  insanity  in  which  there  is  a  similar  combination 
of  pleasurable  feelings,  irritability,  and  pressure  of  activity, 
the  emotional  disturbance  is  believed  to  have  a  similar 
origin.  This  belief  is  substantiated  by  physiological  ex- 
perimentation. In  both  conditions  there  is  no  insight  into 
the  disorder.  The  emotional  attitude  in  both  bears  the 
stamp  of  a  wanton  happiness,  and  self-confidence  is  greatly 
increased. 

The  high  spirits  so  characteristic  of  the  chronic  alcoholic 
represent  another  type  of  morbid  feeling  of  pleasure,  and 
are  designated  drunkard's  humor.  The  same  state  may 
exist  in  delirium  tremens  where,  however,  it  is  mingled  with 
a  sort  of  concealed  fear.  Its  origin  is  unknown,  but  may 
however,  arise  from  the  drunkard's  insusceptibility  to 
humiliation  and  his  moral  apathy  to  vice.  In  paresis  the 
pleasurable  feelings  are  apt  to  be  marked,  especially  the 
feeling  of  well-being.  In  this  disease,  however,  these  feel- 
ings often  exist  unaccompanied  by  motor  excitement,  and 
in  spite  of  the  expansive  ideas,  there  is  absent  the  lack  of 
restraint  and  fresh  energy  that  is  so  characteristic  of  the 
manic  exhilaration.  In  the  later  stages  of  paresis  the  feel- 
ing of  well-being  subsides  to  a  silly  thoughtless  happiness 
without  a  trace  of  the  irritability  which  is  found  in  the 
later  stages  of  the  alcoholic.  In  dementia  prsecox,  during 
the  excited  stages,  pleasurable  feelings  take  on  the  form  of 
a  silly,  purposeless  hilarity  and  exuberance  with  outbursts 
of  silly  laughter,  which,  in  contrast  to  the  hilarity  of  the 
manic  forms  of  manic-depressive  insanity,  seem  to  bear  no 
relation  to  the  patient's  ideas  and  environment. 

Cocain,  morphin,  tobacco,  and  the  bromides  also  produce 
characteristic  feelings  of  well-being.    In  tobacco  smoking 


DISTURBANCES  OF  THE  EMOTIONS  73 

the  feeling  of  agreeable  contemplation  is  due  purely  to  a 
soporific  effect;  the  bromides  produce  a  feeling  of  well- 
being  by  relieving  a  state  of  inner  tension.  The  feeling  of 
ecstasy,  which  occurs  especially  in  epilepsy,  and  sometimes 
in  hysteria,  seems  to  be  very  similar  to  the  dreamy  state 
which  follows  opium  smoking.  The  origin  of  morbid  feel- 
ings of  pleasure  is  very  difficult  to  determine,  both  because 
they  may  arise  from  a  great  many  different  disturbances, 
sometimes  somatic  and  vaso-motor,  sometimes  primarily 
emotional,  and  sometimes  intellectual.  Different  types  of 
feeling  may  exist  at  the  same  time  or  may  succeed  each 
other  rapidly,  as  seen  in  the  mixture  of  fear  and  humor  in 
the  alcoholic  and  of  ecstasy  and  anger  in  the  dreamy  states 
of  the  epileptic. 

Disturbances  of  General  Feelings.  —  General  feelings  are 
those  emotional  states  which  stand  in  close  and  inviolable 
relation  to  self-preservation,  such  as  feelings  of  fatigue  and 
hunger.  They  are  to  be  regarded  as  admonitions,  which 
gradually  develop  out  of  the  experience  of  countless  genera- 
tions into  involuntary  and  instinctive  impulses.  In  ordinary 
life  these  feelings  inform  us  of  our  bodily  needs,  and  they 
imperiously  exact  actions  adapted  to  the  circumstances. 
The  performances  of  these  actions  can  usually  be  inhibited 
by  conscious  volition,  although  often  only  by  means  of  great 
self-denial;  the  feelings  themselves  are,  on  the  contrary, 
only  thoroughly  silenced  when  the  indicated  need  is  relieved 
in  some  way  or  other.  In  normal  life  a  general  feeling 
may  disappear  when  we  pay  no  heed  to  it.  We  are  able 
to  overcome  weariness  when  work  demands  our  strength; 
hunger  abates  when  we  are  unable  for  a  long  time  to  satisfy 
it.  When  at  last  we  have  the  opportunity  to  attend  to  our 
needs  for  rest  and  food,  we  miss  at  first  the  painful  weari- 
ness and  hunger  which  makes  the  restoration  of  our  strength 


74  GENERAL   SYMPTOMATOLOGY 

so  easy.  Only  when  we  have  rested  for  some  time  do  we 
again  experience  a  feeling  of  weariness,  while  hunger  gradu- 
ally returns  as  soon  as  we  begin  to  eat. 

In  normal  life  the  performance  of  mental  and  physical 
work  is  accompanied  by  a  feeling  of  pleasure.  The  basis 
for  this  experience  lies  in  the  fact  that  the  formation  and 
maintenance  of  personality  depends  upon  activity.  If  this 
feeling  of  pleasure  is  absent,  one  regularly  develops  a  form 
of  ennui.  This  is  the  form  of  ennui  that  develops  from 
idleness  and  soon  forces  one  to  some  sort  of  endeavor.  To 
a  normal  man  enforced  idleness  is  most  irritating.  Among 
the  insane  this  form  of  ennui  is  usually  absent  because 
the  patients,  even  although  unemployed,  are  completely  ab- 
sorbed in  their  own  morbid  mental  processes.  The  appear- 
ance of  this  ennui  in  a  patient  may,  therefore,  be  regarded 
as  a  favorable  sign ;  yet  one  must  be  cautious  not  to  confuse 
it  either  with  the  feeling  of  discontent  that  is  often  referred 
to  by  the  dejected  patients  as  ennui,  or  wnth  the  pressure 
of  activity  of  the  manic  patients.  The  complete  absence  of 
ennui  in  dementia  praecox  is  a  very  important  symptom. 
Here  there  is  a  complete  loss  of  volitional  impulse  from 
which  the  desire  for  activity  takes  its  origin.  The  patients 
can  in  spite  of  clear  consciousness  he  abed  weeks  and 
months  without  in  any  way  becoming  uneasy  at  the  lack 
of  activity.  Their  lack  of  ennui  always  indicates  a  pro- 
found disorder  of  the  mental  life,  and  especially  accom- 
panies progressive  deterioration. 

A  wholly  different  significance  attaches  to  that  unpleasant 
feeling  often  designated  as  weariness  which  accompanies 
excessive  exercise  as  a  sign  of  warning.  This  form  of 
weariness  generally  indicates  in  a  normal  individual  an 
actual  need  for  rest;  in  other  words,  fatigue.  Patients 
sometimes  fail  to  show  their  fatigue,  although  there  is  real 


DISTURBANCES  OF  THE  EMOTIONS  75 

need  for  rest.  In  many  excited  states,  especially  in  manic 
forms  of  manic-depressive  insanity,  there  is  often  a  com- 
plete absence  of  fatigue  in  spite  of  the  fact  that  the  patients 
are  exhausted  by  continual  restlessness. 

The  feeling  of  hunger  is  similarly  disturbed  in  these  same 
psychoses.  In  paretic  and  catatonic  patients  there  is  often 
a  senseless  voracity,  although  the  well-nourished  patients 
have  no  need  of  such  an  amount  of  nourishment.  In  the 
constitutional  psychopathic  states  and  in  hysteria,  without 
any  perceptible  relation  to  the  state  of  bodily  nutrition, 
there  may  be  a  prolonged  absence  of  the  feeling  of  hunger, 
which  is  suddenly  replaced  by  gluttony. 

Severe  disturbances  of  the  feeling  of  nausea  are  almost 
always  signs  of  a  far-advanced  deterioration.  Such  patients 
consume  the  most  disgusting  things,  even  their  own  dejec- 
tions. Not  infrequently  they  swallow  nails,  stones,  pieces 
of  glass,  or  animals,  not  only  with  suicidal  intent,  but  con- 
stantly overpowering  their  nausea  from  pure  greediness. 
These  patients  also  lose  those  feelings  which  cause  us 
aversion  at  the  mere  contact  with  filth  or  dirt  and  impel 
one  to  keep  clean,  not  only  the  body,  but  the  whole  en- 
vironment. They  recklessly  soil  themselves,  even  inten- 
tionally, with  their  own  food,  their  own  saliva,  urine,  and 
even  feces. 

The  feelings  of  physical  pain  are  often  abolished.  In 
conditions  of  excitement,  especially  with  intense  fear,  even 
severe  injuries  produce  no  sensation  at  all,  although  con- 
sciousness may  be  perfectly  clear.  Such  patients  pluck  out 
their  tongues  or  eyes,  cut  open  the  abdomen,  etc.,  deeds 
which  would  be  utterly  impossible  for  a  man  with  a  normal 
sense  of  pain.  This  insensibility  to  physical  pain  is  often 
found  in  demented  patients,  especially  in  paretics,  in  whom, 
to  be  sure,  the  destruction  of  the  nervous  conducting  paths 


76  GENERAL  SYMPTOMATOLOGY 

is  an  essential  antecedent.  The  absence  of  the  sensibility 
to  pain  encountered  in  the  hysterical  and  epileptic  patients 
is  essentially  different;  in  these  conditions  the  threshold 
of  pain  only  appears  to  be  raised. 

There  is  finally  a  group  of  feelings  which  pertain  to  the 
maintenance  of  the  race  rather  than  to  self-preservation; 
namely,  the  sexual  feelings.  Among  bewildered  and  excited 
patients  the  feeling  of  shame  may  pass  wholly  into  the  back- 
ground; yet  one  sometimes  observes  distinct  evidences  of 
the  feeling  of  shame  in  the  great  excitement  of  manic- 
depressive  cases  when  it  is  not  overpowered  by  increased 
sexual  feelings.  The  rapid  disappearance  of  the  feeling  of 
shame  even  without  sexual  excitement  is  a  striking  symp- 
tom of  dementia  praecox.  Such  patients  denude  them- 
selves recklessly,  speak  shamelessly  about  sexual  matters, 
and  masturbate  persistently  and  openly.  These  patients 
also  tend  to  employ  obscene  language  (copralalia)  and 
gestures. 

Sexual  feelings  in  mental  disease  are  either  increased, 
abolished,  or  perverted.  Sexual  indifference  occurs  in  many 
forms  of  the  constitutional  psychopathic  states,  and  par- 
ticularly in  hysteria,  also  in  morphinism.  An  increase  of 
sexual  excitability,  which  is  more  frequent,  is  found  in  some 
idiots,  but  in  a  more  pronounced  degree  in  dementia  praecox, 
and  also  in  the  excited  stages  of  paresis,  the  manic  forms 
of  manic-depressive  insanity,  and  in  senile  dementia.  Per- 
verted sexual  feelings  are  those  in  which  sexual  feelings 
occur  exclusively  in  connection  with  persons  of  the  same 
sex,  associations  with  certain  objects,  or  accompanied  by 
brutality  (see  p.  92). 


D.   DISTURBANCE  OF  VOLITION  AND  ACTION 

All  disturbances  of  the  psychic  life  find  their  final  ex- 
pression in  volition  and  action.  The  idea  of  a  definite  aim 
(some  change  either  in  ourselves  or  our  environment)  forms 
the  starting-point  of  a  volitional  act.  This  idea  is  accom- 
panied by  feelings  which  are  converted  into  impulses  for 
the  attainment  of  that  aim.  The  direction  of  any  action 
is  determined,  therefore,  by  an  idea,  while  its  performance 
is  determined  by  the  intensity  and  the  duration  of  the 
accompanying  feelings. 

Morbid  disturbances  of  volition  manifest  themselves  in  the 
most  varied  ways:  the  energy  of  the  volitional  impulse 
can  be  diminished  or  increased;  its  release  facilitated  or 
impeded;  or  the  direction  can  be  modified  by  external  or 
internal  influences;  morbid  impulses  can  forcibly  suppress 
the  normal  will;  or  natural  impulses  can  assume  morbid 
forms;  finally,  the  conduct  of  the  insane  is  naturally  in- 
fluenced by  all  those  disturbances  which  occur  in  other 
spheres  of  their  mental  fife,  although  the  volitional  process 
itself  presents  no  disturbance. 

Diminution  of  Volitional  Impulses.  —  The  complete  sus- 
pension of  volitional  activity  is  termed  paralysis  of  the  will. 
It  is  produced  by  extreme  fatigue,  profound  alcoholic  in- 
toxication, and  in  the  narcoses  of  chloroform,  chloral,  and 
morphin.  It  is  characterized  by  an  absence  of  energy. 
Ordinary  impulses  find  no  issue  in  action,  while  even  the 
most  powerful  incentives  of  personal  well-being  and  moral 
claims   fail    to   influence   the   patient.      A   more   or   less 

77 


78  GENERAL  SYMPTOMATOLOGY 

complete  paralysis  of  the  will  occurs  in  the  end  stages  of 
progressive  mental  deterioration :  senile  dementia,  dementia 
prsecox,  and  paresis.  This  is  characterized  by  a  marked 
diminution  of  personal  initiative,  except  in  gratification  of 
the  lower,  selfish,  and  vegetative  impulses,  such  as  greed, 
gluttony,  and  sexual  desire.  If  left  to  themselves,  the 
patients  are  content  to  sit  around,  inactive,  displaying  very 
little  animation  and  staring  vacantly  into  space.  In  de- 
mentia prsecox  it  can  often  be  shown  that  the  patients  have 
not  lost  the  voluntary  control  of  their  actions,  but  normal 
incentives  fail  to  influence  them.  In  the  end  stages  of 
deterioration  the  only  movements  are  involuntary  and 
reflex.  Similarly,  defective  volition  appears  in  congenital 
imbecility  as  the  result  of  defective  development. 

Increase  of  Volitional  Impulse.  —  The  universal  indication 
of  the  increase  of  volitional  impulse  is  motor  excitement.  But 
we  are  really  justified  in  speaking  of  an  increase  of  volitional 
impulse  only  when  there  is  a  marked  disproportion  between 
the  intensity  of  the  excitation  and  the  importance  of  the 
motives.  In  alcoholic  delirium,  for  example,  we  find  marked 
unrest  which  cannot  be  explained  by  the  patient's  delu- 
sions, hallucinations,  or  emotions,  but  must  be  referred  to  a 
morbid  motor  excitation.  Patients  will  not  remain  in  bed, 
show  a  pronounced  restlessness,  and  constantly  busy  them- 
selves as  if  employed  in  some  occupation.  In  alcoholic  in- 
toxication, increase  of  volitional  impulses  begins  with  simple 
loquacity,  and  increases  to  brawling,  screaming,  and  aimless 
activity.  In  chronic  cocain  intoxication  (see  p.  210)  there 
develops  a  peculiar  motor  excitability  which  seems  to  form 
a  transition  to  the  morbid  pressure  of  oxtivity  which  is  a 
characteristic  symptom  of  manic-depressive  insanity  (see 
p.  387),  and  is  sometimes  found  in  exhaustion  psychoses  and 
paresis. 


DISTURBANCE   OF  VOLITION  AND   ACTION  79 

In  the  lighter  hypomaniacal  disturbances  this  pressure 
of  activity  takes  the  form  of  general  instability  and  busy- 
ness, great  talkativeness,  and  a  tendency  to  animated  ges- 
ticulation. Such  patients  collect  all  sorts  of  useless  things, 
begin  countless  undertakings  which  they  never  finish,  and, 
when  unrestrained,  travel  aimlessly  about.  In  more  marked 
excitement  the  goal  ideas  become  more  and  more  incon- 
stant, and  one  can  hardly  detect  any  purpose  at  all  in  their 
ever  changing,  incoherent  activity.  Patients  scream,  laugh, 
sing,  dance,  disrobe,  tear  their  clothing,  smear  themselves, 
wash  in  their  own  urine,  destroy  everything  they  can  reach, 
and  pound  incessantly  with  their  hands  and  feet. 

Catatonic  excitement  furnishes  a  picture  essentially  dif- 
ferent from  that  of  the  manic  pressure  of  activity.  In 
the  manic  excitement,  all  impulses  lead  to  more  or  less 
purposeful  actions,  though  they  might  at  first  appear  pur- 
poseless and  senseless.  In  catatonia,  on  the  contrary,  we 
have  to  do  with  movements  which  at  most  have  no  definite 
aim.  Although  the  characteristic  excitement  in  catatonics 
is  often  more  moderate,  the  movements  are  entirely  pur- 
poseless. Such  patients  make  grimaces,  contort  the  body, 
run  about,  clap  their  hands,  and  utter  a  succession  of  sense- 
less noises.  These  movements  are  not  pure  volitional  acts, 
as  there  is  no  antecedent  idea  of  their  purpose.  Patients 
themselves  often  assure  us  that  they  do  not  know  why 
they  perform  such  absurd  antics. 

Impeded  Release  of  the  Volitional  Impulse.  —  The  strength 
and  rapidity  with  which  a  volitional  impulse  is  converted 
into  action  is  dependent,  not  only  on  its  own  intensity,  but 
also  on  the  resistance  which  it  has  to  overcome.  Thus,  fright 
and  fear  may  present  obstacles  to  the  realization  of  our 
intention,  which  can  be  overcome  only  by  the  most  strenuous 
exertion  of  the  will. 


80  GENERAL  SYMPTOMATOLOGY 

The  psychomotor  retardation,  which  is  the  most  important 
disturbance  in  the  depressed  states  of  manic-depressive  in- 
sanity, is  probably  due  to  a  similar  increase  of  resistance. 
Such  patients  require  special  exertion  of  the  will  for  al- 
most every  movement.  All  the  actions  are  characteristically 
slow  and  weak,  except  when  a  powerful  emotional  shock 
breaks  through  the  resistance.  The  retardation  may  be- 
come less  pronounced  under  the  influence  of  continued  effort. 
In  severe  cases  independent  volitional  action  is  almost  im- 
possible. In  spite  of  every  apparent  exertion,  the  patients 
cannot  utter  a  word  or  at  best  answer  only  in  monosyllables, 
and  are  unable  to  eat,  stand  up,  or  dress.  As  a  rule  they 
clearly  recognize  the  enormous  pressure  lying  upon  them, 
which  they  are  unable  to  overcome.  The  name  "  stupor  " 
is  usually  applied  to  these  disturbances,  but  they  are  only 
superficially  related  to  the  stupor  of  catatonia. 

In  catatonic  stupor  the  release  of  movements  in  itself  is 
not  rendered  difficult,  as  action  is  occasionally  both  rapid 
and  powerful.  But  every  impulse  is  almost  immediately 
followed  by  the  release  of  an  opposing  impulse  which  pre- 
vents the  consummation  of  the  act.  Thus,  we  often  see  the 
desired  movement  begin  all  right,  but  it  is  immediately  in- 
terrupted and  extinguished  by  the  opposing  impulse.  Here 
the  impulse  is  not  hindered  by  internal  resistance,  but  is 
simply  quenched  by  a  counter  impulse.  In  contrast  to  the 
retardation,  in  which  there  is  a  continuous  hindrance,  one 
might  refer  to  this  as  a  blocking.  As  soon  as  the  block- 
ade is  raised,  the  counter  order  disappears,  and  the  action 
proceeds  without  the  slightest  difficulty. 

As  a  result  of  this  blocking  of  the  will  many  reactions 
which  normally  occur  without  special  act  of  volition  are 
suppressed  at  their  inception.  The  patients  will  not  look 
up  when  accosted,  or  shake  hands  when  the  hand  is  proffered. 


DISTURBANCE  OF  VOLITION  AND  ACTION  81 

If  one  threatens  them  with  a  knife,  or  pricks  the  eyelid,  they 
may  perchance  shrink  away,  but  they  never  make  any  well- 
directed  effort  to  protect  themselves;  they  continue  to  lie 
in  the  most  uncomfortable  positions,  and  will  sit  for  hours 
in  the  sun,  when  by  taking  a  couple  of  steps  they  could 
reach  the  shade.  Possibly  the  persistent  holding  open  of 
the  eyelids,  the  regular  swallowing  of  saliva,  and  the  reten- 
tion of  urine  and  feces  may  be  explained  in  this  way.  The 
whole  attitude  of  the  patient  becomes  strained  and  un- 
natural. 

In  blocking  of  the  will  there  is  no  lack  of  impulses,  but 
rather  a  balance  of  counter  impulses.  Hence  we  do  not 
find  the  lassitude  characteristic  of  retardation  but  a  rigid 
tension,  which  discloses  the  play  of  opposing  influences. 
Movements  take  place  with  an  excess  of  tension  which  ex- 
tends almost  equally  over  all  associated  groups  of  muscles: 
the  resulting  action  depends  on  relatively  slight  preponder- 
ance of  one  group  of  muscles  over  the  opposite  group. 
Hence  both  station  and  movement  appear  tense  and  stiff. 
Occasionally  the  relative  strength  of  impulse  and  counter- 
impulse  varies,  sometimes  one  and  sometimes  the  other 
gaining  the  upper  hand.  A  movement  suddenly  stops  and 
then  just  as  suddenly  begins  again.  It  proceeds  by  jerks 
and  is  awkward  and  clumsy.  Possibly  it  is  the  conscious- 
ness of  all  this  opposition  that  leads  to  the  innervation  of 
more  remote  muscle  groups.  The  entire  limb  is  apt  to 
come  into  play  for  the  simplest  movements,  which  thereby 
become  ponderous  and  indefinite. 

Facilitated  Release  of  Volitional  Impulses.  —  Both  the 
impressions  of  the  outer  world  and  our  inner  experience 
develop  in  us  continually  more  or  less  tension  of  the  will, 
which  tends  to  relieve  itself  in  the  most  varied  expressions. 
Part  of  these  operations  are  independent  of  voluntary  con- 


82  GENERAL  SYMPTOMATOLOGY 

trol.  The  greater  part  of  them,  however,  are  subject  to 
inhibition  through  voluntary  effort.  The  ease  with  which 
impulse  is  converted  into  action  depends  upon  the  devel- 
opment of  the  inhibitions  which  we  control.  Our  mental 
development  means  in  general  an  increase  of  inhibitions. 
The  child  reacts  immediately,  while  growing  self-control 
enables  the  man  to  suppress  numberless  impulses,  before 
they  develop  into  action.  The  female  sex  with  its  height- 
ened emotional  irritability  tends  to  remain  on  the  plain  of 
the  child. 

The  restraining  power  of  the  inhibitions  naturally  depends 
on  the  strength  of  the  impulses  and  the  intensity  of  the 
emotional  state,  from  which  they  originate.  On  the  other 
hand,  there  are  well-recognized  influences  that  facilitate 
the  release  of  impulses  and  thereby  lessen  the  resistance  to 
the  conversion  of  an  impulse  into  action.  This  operates  to 
a  greater  or  less  degree  in  all  forms  of  psychomotor  activity. 
'Whenever  movements  are  continued  there  arises  a  certain 
degree  of  excitement  which  means  a  diminution  of  inhibi- 
tion. Indeed,  it  has  already  been  pointed  out  that  morbid 
inhibition  is  gradually  reduced  by  activity.  Still  more  evi- 
dent is  the  increase  of  excitement  in  manic  and  catatonic 
patients  when  their  restlessness  is  not  restrained.  An  un- 
restrained discharge  of  impulses  always  makes  it  more  diffi- 
cult for  the  patients  to  control  themselves. 

A  most  significant  diminution  of  inhibition  is  produced 
by  alcohol.  Ether  and  cocain  have  a  similar  effect  both 
in  the  acute  and  chronic  intoxications. 

The  facilitated  release  of  volitional  impulse  is  a  constant 
symptom  in  some  forms  of  morbid  constitution,  especially 
in  hysteria.  In  this  disease  the  intensity  of  the  emotions 
leaves  little  room  for  the  reasoned  action,  hence  these  patients 
sometimes  suddenly  find  themselves  performing  strange  and 


DISTURBANCE  OF  VOLITION  AND  ACTION  83 

incomprehensible  acts,  as  thieving,  cheating,  and  self -muti- 
lation, apparently  at  variance  with  their  intention. 

Heightened  Susceptibility  of  the  Will.  —  The  motives  of 
action  have  two  sources:  external  stimuli;  and  those 
relatively  constant  principles  of  action  which  arise  from 
within  rather  than  from  without,  and  render  the  individual's 
conduct  more  or  less  independent  of  his  surroundings.  The 
control  of  actions  by  these  general  principles  is  lacking  only 
in  children  and  unstable  individuals.  In  diseases  this  con- 
trol is  lost  in  weakness  of  the  will,  increased  psychomotor 
excitability,  and  in  conflict  with  overwhelming  morbid 
impulses. 

Weakness  of  will  is  found  in  all  forms  of  imbecility,  where 
the  fixed  principles  of  action  are  lacking.  There  is  no  in- 
ternal unity  or  consistency  in  conduct.  The  chief  charac- 
teristic is  a  hypersuggestibility,  through  which  the  patients 
'become  the  prey  to  every  accidental  influence.  This  con- 
dition is  found  in  its  purest  form  in  paresis.  Similar 
phenomena  are  induced  through  suspension  of  these  fixed 
principles  of  action  by  means  of  hypnotism. 

Transient  hypersuggestibility  is  found  in  catalepsy,  where 
often  the  limbs  of  the  patient  will  remain  in  any  position 
in  which  they  are  placed  until,  as  the  result  of  extreme 
muscular  exhaustion,  they  tremblingly  obey  the  laws  of 
gravity.  In  this  condition  there  is  often  found  a  moderate, 
but  constant,  muscular  resistance  called  cerea  flexibilitas, 
in  which  it  is  possible  to  mould  the  limbs  into  any  desired 
position.  Less  often  patients  are  found  who  will  repeat  for 
some  time  any  simple  movement,  once  started,  or  who  will 
laboriously  imitate  everything  done  in  their  presence  —  echo- 
praxia.  In  echolalia  the  patient  involuntarily  repeats 
every  word  he  hears,  although  at  the  same  time  giving 
evidence  of  considerable  elaboration  of  impressions  by  his 


84  GENERAL  SYMPTOMATOLOGY 

ability  to  solve  simple  problems.  Indications  of  these  symp- 
toms, especially  cerea  flexibilitas,  are  occasionally  observed 
in  the  most  varied  diseases,  such  as  hysteria,  epilepsy, 
manic  forms  of  manic-depressive  insanity,  paresis,  and 
alcoholism;  but  the  whole  group  of  symptoms  is  most 
pronounced  in  dementia  praecox,  especially  the  catatonic 
form. 

Distractibility  of  the  will  is  a  morbidly  easy  translation  of 
ideas  into  action.  It  usually  accompanies  heightened  sus- 
ceptibility of  the  will,  but  is  differentiated  from  it  by  a 
reaction  to  internal  as  well  as  to  external  stimuli.  It  is 
to  conduct  what  the  distractibility  of  the  attention  is  to 
intellection,  and  effectually  prevents  all  permanent  volitional 
control  of  action.  Sudden  resolutions  are  half  carried  out 
only  to  yield  to  new  ones.  The  patients  are  wholly  under 
the  influence  of  the  environment,  whether  good  or  bad. 
Distractibility  of  the  will  is  found  in  certain  conditions  of 
manic  and  delirious  excitement.  It  accompanies  hyste- 
ria and  some  forms  of  imbecility  as  a  permanent  personal 
characteristic. 

Interference  and  Stereotypy.  —  The  carrying  out  of  any 
simple  act  is  in  general  determined  by  the  goal  idea.  Since 
our  movements  are  usually  governed  by  the  principle  of 
economy,  we  seek  to  reach  the  goal  with  minimum  expendi- 
ture of  strength  and  time.  In  case  this  principle  is  clearly 
transgressed,  or  if  the  act  is  clearly  inappropriate,  we  have  a 
disturbance  of  conduct  which  is  provisionally  called  inter- 
ference, in  which  the  correspondence  between  intention  and 
accomplishment  is  interfered  with  by  the  interpolation  of 
incongruous  impulses.  Here,  apparently,  incidental  im- 
pulses break  into  the  natural  flow  of  conduct.  A  similar 
condition  obtains  in  the  blocking  of  the  will.  One  may 
regard  the  blocking  of  the  will  as  a  special  case  in  which  the 


DISTURBANCE  OF  VOLITION   AND  ACTION  85 

incidental  impulses  are  directly  opposed  to  the  original  im- 
pulses; then  interference  would  be  regarded  as  a  crossing 
of  the  original  impulses  by  the  incidental  impulses  in  various 
directions.  The  blocking  of  the  will  would  then  be  only 
a  special  form  of  the  general  disturbance  which  may  be 
described  as  a  crossing  of  the  voluntary  impulses.  Both 
symptoms  belong  to  catatonia. 

The  incidental  impulses  may  influence  action  in  many 
different  ways.  The  simplest  form  is  probably  seen  in  the 
reiterated  repetition  of  chance  impulses.  Normally  every 
impulse,  as  soon  as  the  aim  is  realized,  is  forced  into  the 
background  by  other  impulses.  But  where  the  pursuit  of 
any  definite  aim  is  disturbed  and  there  still  remains  a 
general  pressure  of  activity,  any  impulse  once  released  has 
a  good  chance  to  be  repeated  as  long  as  the  active  residua 
of  the  impulse  are  not  obliterated  by  new  aims.  Such  an 
impulse  becomes,  so  to  speak,  an  incidental  impulse  which 
breaks  through  the  more  or  less  aimless  operations  of  the 
will  and  becomes  more  insistent  with  each  repetition.  This 
disturbance  is  called  stereotypy  (Kahlbaum). 

Whenever  stereotypy  is  marked  (a)  by  a  blocking  of  the 
will  we  find  a  continuous  tension  of  definite  muscle  groups; 
whenever  it  is  marked  (b)  by  crossing  of  voluntary  impulses 
we  find  a  reiterated  repetition  of  the  same  movement. 
(a)  In  muscular  tension  the  patients  remain  in  the  same 
place  and  attitude  for  an  almost  incredible  length  of  time 
in  spite  of  the  greatest  discomfort.  They  stand  in  the  same 
corner,  kneel  in  a  definite  place,  lie  in  bed  with  legs  curled 
up  and  head  extended,  so  rigid  that  they  can  be  lifted  like 
a  log.  Others  grip  a  piece  of  bedspread  with  their  teeth, 
or  convulsively  grasp  a  piece  of  bread  or  torn-off  button. 
The  expression  of  the  countenance  is  also  rigid,  mask-like, 
the  forehead  drawn  up  as  if  in  surprise,  the  eyebrows  ele- 


86  GENERAL  SYMPTOMATOLOGY 

vated  and  the  eyes  often  wide  open.  The  eyeballs  are  often 
turned  sidewise  and  the  lips  are  protruded  like  a  snout. 

(b)  Stereotyped  movements  have  an  unlimited  variety.  The 
patients  turn  somersaults,  rap  rhythmically,  walk  about  in 
peculiar  places,  hop,  jump  up  and  down,  roll  and  creep  on 
the  ground,  pick  at  the  clothing  or  hair,  and  grit  the  teeth. 
These  movements  can  be  repeated  innumerable  times,  for 
weeks  or  even  months.  In  all  these  movements  the  patients 
are  absolutely  reckless  of  themselves  and  their  environment. 

Mannerisms  are  a  kind  of  stereotyped  movement,  con- 
sisting of  ordinary  movements  peculiarly  modified.  The 
patients  walk  with  a  peculiar  gait,  drag  one  foot,  go  in 
straight  lines  or  in  circles,  hold  their  spoons  at  the  very 
end,  eat  in  a  definite  rhythm,  and  shake  hands  with  stiffly 
extended  fingers.  Mannerisms  are  especially  common  in 
speech.  Grunts,  lisping,  peculiar  words,  phrases,  and  in- 
flection, and  numerous  repetitions  of  the  same  words  are 
among  the  most  frequent  forms.  Stereotypy  is  a  charac- 
teristic of  the  catatonic  forms  of  dementia  praecox,  but  also 
occurs  in  exhaustion  psychoses  and  in  paresis,  where  it  is 
only  a  transient  symptom. 

In  the  end  stages  of  catatonia  there  is  occasionally  ob- 
served a  form  of  stereotypy  which  is  scarcely  the  same 
as  that  just  described.  It  consists  of  peculiar  rhythmical 
movements,  especially  rocking  the  body  while  sitting  and 
standing,  nodding  or  shaking  the  head,  clapping  of  the 
hands,  etc.  This  symptom  always  indicates  a  complete 
deterioration  of  the  will.  It  is  likewise  observed  in  the 
most  profound  idiocy.  It  is  a  fair  hypothesis  that  these 
movements  are  the  expression  of  certain  primitive  arrange- 
ments of  our  nervous  system,  which  in  the  absence  of  the 
higher  processes  determine  the  activities. 

In  stereotypy  voluntary  activity  never  proceeds  to  a  goal. 


DISTURBANCE  OF  VOLITION  AND  ACTION  87 

Even  when  the  patients  are  active  their  activities  move  in  a 
circle.  On  the  other  hand,  there  is  a  type  of  crossing  of 
impulses  in  which  the  incidental  impulses  produce  only  a 
superfluous  embellishment  of  the  intended  act.  The  act  is 
finally  accomplished,  but  only  after  all  sorts  of  additions  and 
deviations.  The  patients  skitter  along,  go  backward,  walk 
on  their  knees,  bend  away  backward,  or  drag  one  foot: 
they  extend  their  hands  in  wide  circles,  or  with  sudden 
swoops  or  stiff  jerks.  In  shaking  hands  they  touch  one's 
hand  only  with  the  little  finger,  or  with  the  back  of  the 
hand.  In  eating  they  grasp  the  spoon  by  the  tip,  arrange 
the  food  in  little  piles,  or  count  seven  between  each  mouth- 
ful; the  water  is  drunk  in  little  sips  or  after  long  pauses. 
The  bed  clothing  and  their  garments  are  arranged  in  a 
peculiar  way.  The  catatonic  grimacing  may  also  be  re- 
garded as  belonging  here. 

From  this  embellishment  of  conduct  there  are  regular 
transitions  to  those  disturbances  which  have  been  termed 
by  Schules  derailment  of  the  will,  where  acts  are  completed 
very  differently  from  the  way  in  which  they  are  begun. 
For  instance,  in  grasping  the  spoon  to  eat  the  patients  may 
twirl  it  about  in  a  circle,  then  lay  it  down  again,  or  in  carry- 
ing a  glass  of  water  to  the  mouth  upset  it  on  the  table, 
suddenly  turn  it  upside  down,  and  return  it  to  the  table. 

Also  in  their  speech  it  is  often  observed  that  the  patients 
will  suddenly  stop  and  begin  anew  with  another  thought, 
which  in  turn  is  just  as  abruptly  left  for  another,  so  that 
the  goal  idea  is  finally  lost  sight  of.  It  is  in  this  way  that 
desultoriness  arises  (see  p.  40).  In  this  crossing  of  im- 
pulses many  of  the  acts  stand  in  no  definite  relation  to  any 
goal  idea.  The  patient  suddenly  beats  his  companion, 
perches  himself  like  a  bird  on  the  foot  of  the  bed,  grips 
his  finger  in  the  anus,  stands  on  his  head,  or  filths  on  his 


88  GENERAL  SYMPTOMATOLOGY 

dinner  plate.  Occasionally,  aggressive  and  violent  attacks 
originate  in  this  way. 

In  this  derailment  of  impulses  one  gets  the  impression 
that  the  original  purpose  in  the  act  is  forced  into  the  back- 
ground; for  instance,  the  patient  will  exert  the  greatest 
effort  of  the  will  when  started  in  a  certain  direction  when 
he  could  easily  succeed  by  making  a  little  detour.  He  will 
push  persistently  against  a  locked  door  toward  which  he 
has  started  when  he  could  easily  leave  the  room  by  an  open 
door  close  at  hand. 

Diminished  Susceptibility  of  the  Will.  —  In  the  description 
of  the  blocking  of  the  will  it  was  shown  how,  under  cer- 
tain circumstances,  ever}7  impulse  of  the  will  can  be  rendered 
ineffective  by  counter  impulses.  The  blocking  of  the  will  is 
but  a  partial  symptom  of  a  very  general  disturbance ;  namely, 
the  impulsive  resistance  to  every  outer  influence  of  the  will, 
which  by  Kahlbaum  has  been  designated  negativism.  In 
negativism  there  is  a  blocking  of  all  external  impressions, 
an  inaccessibility  to  social  intercourse,  and  an  opposition  to 
every  request;  and  it  may  even  extend  to  the  regular  per- 
formance of  contrary  actions  (the  negativism  of  command), 
and  finally  to  the  suppression  of  nature's  demands,  as  in 
micturition. 

In  this  way  conduct  in  every  respect  becomes  just  the 
opposite  of  that  which  is  striven  for  and  that  which  would 
be  expected  normally.  Patients  do  just  the  opposite  of 
that  which  they  are  requested  to  do:  press  their  teeth 
together  when  asked  to  show  their  tongue,  close  the 
eyes  when  an  attempt  is  made  to  examine  their  pupils, 
and  refuse  to  answer  questions  —  mutism,  although 
they  sometimes  speak  spontaneously.  They  offer  the 
most  powerful,  but  almost  always  passive,  resistance  to 
every  external  encroachment:    will  not  allow   any  one   to 


DISTURBANCE  OF  VOLITION  AND  ACTION  89 

dress  or  undress  them,  will  not  bathe  or  take  care  of 
themselves,  and  offer  strenuous  resistance  to  compulsory 
feeding,  but  when  unmolested  eat  greedily.  The  feces 
are  often  retained  with  the  greatest  exertion,  especially  if 
the  patients  are  taken  to  the  closet.  As  soon  as  they  are 
returned  to  bed,  the  evacuation  immediately  takes  place. 
They  persist  in  leaving  their  own  bed  and  crawling  into 
others,  likewise  they  will  smear  and  spoil  their  own  food, 
although  it  may  be  even  better,  and  steal  or  fight  for  that  of 
their  companions.  The  impulsive  character  of  its  origin  is 
most  clearly  demonstrated  in  the  occasional  cases  of  nega- 
tivism to  requests.  Such  patients  continue  lying  on  their 
back  if  requested  to  arise,  or  they  turn  around  if  asked 
to  go  forward,  and  remain  silent  if  told  to  speak. 

Negativism  is  not  due  to  voluntary  opposition.  Patients 
sometimes  admit  after  the  attack  that  they  do  not  know 
why  they  acted  as  they  did.  Negativism,  stereotypy,  and 
loss  of  will  probably  all  have  the  same  basis.  They  often 
occur  in  the  same  patient,  and  may  be  easily  made  to  pass 
into  one  another.  These  various  disturbances  of  the  will 
are  most  frequent  in  catatonia,  and  are  sometimes  found 
in  a  less  pronounced  form  in  paresis,  senile  dementia,  and 
idiocy. 

Catatonic  negativism  must  not  be  confused  with  the  con- 
scious resistance  of  terrified  patients.  In  catatonia  there  is 
no  conscious  reason  for  resistance,  and  no  persuasion  can 
overcome  it.  It  is  not  influenced  by  pain,  and  the  manner 
of  resistance  is  always  constrained  and  often  absurdly  in- 
appropriate. The  stubbornness  of  imbecility,  epilepsy, 
hysteria,  paresis,  and  senile  dementia  is  closely  allied  to 
negativism,  but  in  contrast  to  negativism  it  always  starts 
with  an  idea,  and  is  more  or  less  influenced  by  persuasion, 
new  ideas,  and  emotional  changes.     Moreover,  in  stubborn- 


90  GENERAL  SYMPTOMATOLOGY 

ness  the  general  emotional  attitude  is  fretful,  irritable,  and 
unruly.  The  patient  shows  fight,  and  is  often  dominated 
by  confused,  malevolent  delusions,  whereas  the  negativistic 
patient  shows  great  equanimity,  seldom  defends  himself, 
and  almost  never  attacks,  but  merely  resists. 

Compulsive  Acts.  —  Compulsive  acts  are  those  which  do  not 
arise  from  normal  antecedent  consciousness  of  motive  and 
desire,  but  seem  to  the  patient  to  be  forced  upon  him  by  a  will 
which  is  not  his  own.  As  a  rule,  the  patients  struggle  against 
the  morbid  impulses;  often  caution  those  about  them  at 
their  approach,  and  adopt  measures  to  prevent  harm  to 
others.  The  accomplishment  of  the  act  is  accompanied  by 
a  feeling  of  relief,  and  is  usually  followed  by  clear  insight 
into  the  nature  of  the  act,  accompanied  by  chagrin  and 
remorse. 

Compulsory  acts  are  generally  accompanied  by  great  emo- 
tional excitement,  and  stand  in  close  relation  to  compulsory 
ideas  and  fears  already  described  (see  p.  69).  These  dis- 
turbances all  originate  on  a  basis  of  congenital  morbid  en- 
dowment, and  are  all  a  part  of  the  symptoms  of  the  con- 
stitutional psychopathic  states. 

Impulsive  Acts.  —  Impulsive  acts  are  distinguished  from 
compulsive  acts,  in  that  they  do  not  seem  to  the  patient  to  be 
influenced  from  without,  but  are  the  direct  expression  of  a 
sudden  overwhelming  impulse,  which  gives  no  chance  for  reflec- 
tion or  resistance. 

They  are  found  in  the  most  varied  morbid  conditions. 
Probably  the  pressure  of  activity  in  manic  forms  of  manic- 
depressive  insanity  is  of  this  type.  Here  belong  also  the 
wanderings  and  assaults  of  the  epileptic  (see  p.  446), 
the  excesses  of  the  dipsomaniac,  as  well  as  the  morbid 
impulses  of  hysteria,  self-inflicted  injury,  theft,  and  fraud, 
Their  origin  does  not  lie  in  definite  feelings  of  pleasure  or 


DISTURBANCE  OF  VOLITION  AND  ACTION  91 

dislike,  but  in  marked  motor  excitement.  The  outbursts 
of  the  catatonic  are  thoroughly  representative  of  impulsive 
acts,  although  the  basis  lies  not  in  a  pleasurable  or  un- 
pleasurable  feeling  but  in  a  powerful  pressure  of  movement. 
The  patient  is  controlled  by  the  consciousness  that  he  must 
do  this  or  that,  without  a  definite  reason  and  without  fore- 
thought, although  he  sometimes  appreciates  the  foolishness 
of  his  act.  Occasionally  there  is  an  idea  that  his  limbs  are 
controlled  by  an  invisible  power,  as  God,  the  devil,  or  some 
electrical  influence.  The  patient's  consciousness  is  domi- 
nated by  one  blind  impulse  without  clear  motive  or  realiza- 
tion of  the  outcome.  There  is  no  opportunity  to  resist  the 
impulse.  The  execution  is  rapid  and  reckless,  and  the  pa- 
tients are  correspondingly  dangerous.  This  is  clearly  seen 
in  the  impulsive  acts  of  the  catatonic,  such  as  the  shouting, 
sudden  attacks,  denuding,  the  senseless  attempts  to  strangle 
themselves,  to  cut  out  the  tongue,  and  to  gouge  out  the 
eyes. 

Morbid  Impulses.  —  A  disturbance  of  the  natural  impulses 
is  a  symptom  of  all  general  morbid  changes  of  volitional 
action.  In  paralysis  and  inhibition  of  psychic  processes  all 
the  appetites  are  diminished;  in  excitement,  on  the  other 
hand,  appetites  are  increased,  especially  sexual  desires.  The 
latter  seldom  lead  to  actual  assault,  but  manifest  themselves 
in  ambiguous  phrases,  abusive  language,  and  by  more  or 
less  reckless  masturbation:  in  women,  by  shameless  ex- 
posures, extreme  uncleanliness,  or  incessant  washing  with 
water,  saliva,  or  urine,  combing  and  unloosing  the  hair;  in 
lighter  forms,  by  adornment  and  flirtation,  by  an  alterna- 
tion between  seductive,  shamefaced,  and  sentimental  man- 
ners, by  hand  pressing,  letter  writing,  significant  glances, 
and  the  like.  Less  frequently  in  manic  excitement  there 
is  found  an  increased  desire  for  food,  although  restlessness 


92  GENERAL  SYMPTOMATOLOGY 

usually  hinders  the  patients  from  taking  sufficient  nourish- 
ment. On  the  other  hand,  excessive  greediness  is  not  in- 
frequently found  in  idiots,  paretics,  and  especially  in  cata- 
tonics.  Incredible  quantities  of  the  most  unpalatable  and 
disgusting  things,  sand,  stones,  seaweed,  feces,  etc.,  are 
sometimes  devoured  by  such  patients.  In  these  last  cases 
there  is  not  a  simple  increase  of  healthy  impulses,  but  prob- 
ably a  simultaneous  perversion  of  the  appetite  both  in  nature 
and  direction.  The  same  is  true  of  the  well-known  excessive 
desire  for  eating  suddenly  manifested  by  pregnant  women. 
Much  more  numerous,  however,  are  the  morbid  sexual  im- 
pulses, which  in  recent  years  have  been  most  thoroughly 
investigated.  The  most  pronounced  of  these  are  the  con- 
trary sexual  instincts,  in  which  the  sexual  feelings  and  desires 
are  exclusively  directed  toward  members  of  the  patients'  own 
sex. 

Sadism  consists  in  the  attempt  to  increase  or  induce 
sexual  excitement  by  brutality.  In  the  final  stage  of  its 
development  actual  sexual  congress  is  a  matter  of  indiffer- 
ence. In  masochism,  on  the  other  hand,  the  endurance  of 
pain  increases  sexual  excitation  or  may  be  substituted  for 
it.  The  satisfaction  of  sadism  appears  to  arise  from  the 
feeling  of  absolute  power  over  the  victim,  while  that  of 
masochism  arises  from  the  most  complete  subjection  to  the 
will  of  another.  In  fetichism  particular  articles  of  clothing 
or  parts  of  the  body  become  either  the  necessary  adjuncts 
for  satisfactory  coitus,  or  the  simple  observation  or  contact 
with  the  feticlumay  satisfy  the  sexual  impulse.  The  most 
common  fetiches  are  boots,  shoes,  handkerchiefs,  under- 
clothing, and  finally  velvet  and  furs. 

Besides  the  perversion  of  normal  impulses  as  seen  iii  the 
above,  there  is  a  group  of  morbid  impulses  which  seem  to 
bear  no  relation  to  normal  life.     Such  are  kleptomania,  the 


DISTURBANCE  OF  VOLITION   AND  ACTION  93 

irresistible  impulse  to  steal  all  manner  of  worthless  and 
useless  things;  'pyromania,  the  impulse  to  burn.  Both 
these  usually  arise  on  the  basis  of  an  epileptic  or  hysterical 
endowment. 

The  whole  series  of  abnormal  impulses  are  partial  symp- 
toms of  a  general  morbid  endowment,  and  indicate  con- 
genital degeneracy.  It  is  possible  that  kleptomania  and 
pyromania  should  be  regarded  as  compulsive  acts.  The 
impulse  appears  as  an  obtrusive  compulsion  which  is  re- 
sisted as  long  as  possible,  while  the  performance  of  the  act 
is  accompanied  by  a  feeling  of  relief. 

Disturbances  of  Expression.  —  The  movements  by  which 
patients  express  their  ideas,  feelings,  and  impulses  are 
among  the  most  important  clews  to  morbid  psychic  impulses. 
A  full  delineation  of  the  symptoms  of  the  various  disease 
types  occurs  in  the  clinical  portion  of  this  work.  In  this 
place  we  confine  ourselves  to  a  few  characteristic  indications. 

Dementia  prsecox  is  indicated  by  lack  of  interest,  not- 
withstanding accurate  apprehension,  by  listlessness,  strained 
attitudes,  senseless  grinning  or  laughter,  with  sudden  im- 
petuous movements.  In  dementia  praecox  the  change  that 
occurs  in  the  character  of  movements  is  very  striking, 
particularly  the  loss  of  grace.  The  catatonic  movements 
are  either  stiff  and  wooden  on  account  of  the  superfluous 
tension;  or  careless  and  listless  as  a  result  of  an  insufficient 
expenditure  of  energy;  and  again  they  are  gross  and  awk- 
ward because  associated  groups  of  muscles  are  involved  in 
the  movements.  The  naturalness  of  the  movements  is 
destroyed  by  the  tendency  to  ornamentation,  which  gives 
them  the  appearance  of  being  affected,  and  finally  there  is 
a  lack  of  uniformity  in  the  movements  of  expression. 

Paretics  may  often  be  recognized  by  their  awkward 
friendliness  and  production  of  silly  expansive  ideas.     De- 


94  GENERAL  SYMPTOMATOLOGY 

pressed  patients  sit  around  collapsed  and  flaccid,  with 
troubled  expression.  Their  movements  are  slow  and  la- 
borious. The  apprehensive  patients  are  restless,  bite  their 
nails,  and  wring  their  hands.  In  extreme  retardation,  they 
lie  motionless  in  bed  with  fixed  expression  and  whisper  their 
answers  with  great  exertion.  The  manic-depressive,  on 
the  contrary,  moves  rapidly  about,  talks,  cries,  sings,  plays 
tricks  on  his  fellows,  and  busies  himself  with  all  sorts  of 
things.  The  hysterical  patients  arrange  their  clothing  and 
hair  to  make  an  impression.  The  paranoiac  endures  his 
hospital  confinement  with  dignity,  carrying  with  him  the 
documents  which  prove  all  his  pretensions. 

Alterations  of  speech  and  writing  are  of  the  greatest 
diagnostic  value.  Delusions  are  usually  betrayed  by  the 
content  of  the  communications.  In  manic  patients  there 
is  incessant  babbling,  with  a  tendency  to  puns  and  rhymes. 
This  is  also  found  in  excited  paretics  with  more  or  less  dis- 
turbance of  articulation.  In  both  diseases  speech  may 
be  reduced  to  an  incomprehensible  gibberish,  though  from 
different  causes. 

In  retarded  patients  speech  is  low  and  difficult.  Melan- 
choliacs  express  their  thoughts  laconically,  and  often  keep 
up  a  monotonous  lamentation.  Catatonics  are  often  mute 
for  weeks  at  a  time,  and  then  suddenly  begin  to  speak 
fluently  or  sing,  although  more  or  less  confusion  of  speech 
is  always  present.  Their  stereotypy  is  manifested  by  con- 
stant repetition  of  the  same  words,  phrases,  or  even  sense- 
less syllables,  while  they  frequently  make  up  entirely  new 
words. 

Disturbances  of  writing  correspond  both  in  content  and 
form  with  those  of  speech.  The  manic-depressive  patient 
fills  sheet  after  sheet  of  paper  with  large,  showy,  and  hastily 
written  characters,  which  are  often  illegible  even  to  the 


DISTURBANCE  OF  VOLITION  AND  ACTION  95 

writer.  The  paretic's  writing  shows  omission,  misplace- 
ment of  words  and  syllables,  blots,  untidy  corrections,  and 
uncertainty.  Hysterical  patients  use  innumerable  marks 
for  emphasis.  In  melancholiacs  the  individual  characters  are 
incomplete,  small,  and  crowded.  The  same  is  true  in  re- 
tardation. Catatonic  patients  cover  the  paper  with  unin- 
telligible scrawls,  endlessly  repeated  —  written  verbigwation. 

In  psychoses  associated  with  brain  lesions  there  are  apt 
to  be  present  disturbances  of  speech  and  writing  such  as 
aphasia,  paraphasia,  agraphia,  paragraphia,  perseveration, 
inability  to  read  and  to  combine  letters  into  words  and 
syllables,  indistinct  enunciation,  scanning  or  monotonous 
speech,  also  ataxia  in  writing. 

Conduct  arising  from  a  Morbid  Basis.  —  Since  conduct  is 
the  expression  of  the  entire  psychic  life,  we  readily  under- 
stand why  it  is  more  or  less  seriously  disturbed  by  morbid 
changes  in  any  part  of  the  psychic  individual,  while,  on  the 
other  hand,  no  isolated  act  can  be  taken  as  an  infallible 
index  of  the  exact  morbid  condition.  Delusions  of  sinful- 
ness impel  patients  to  penance,  self-mutilation,  or  suicide. 
Delusions  of  persecution  lead  to  mysterious  precautions,  to 
misanthropic  isolation,  to  restless  wandering,  or  even  to 
outbursts  of  rage  and  murderous  attacks  against  supposed 
enemies.  Hypochondriacal  delusions  may  lead  to  revolt- 
ing smearing,  self-mutilation,  or  injurious  and  absurd  cura- 
tive attempts,  often  with  the  evident  purpose  of  attracting 
attention  and  sympathy. 

Mental  excitement  very  soon  leads  to  conflicts  with  the 
environment,  to  breaches  of  the  public  order,  and  quite  often 
to  resistance  to  civic  authority.  Patients  behave  in  a  reck- 
less and  striking  manner.  They  are  ungovernable,  irritable, 
and  violent  under  contradiction  and  restraint.  At  first 
they  act  as  if  intoxicated,  and  later  become  still  more  rest- 


96  GENERAL  SYMPTOMATOLOGY 

less  and  even  dangerous.  There  is  usually  also  a  tendency 
to  sexual  excesses,  in  which  they  indulge  without  regard  to 
decency  or  morality.  Such  excited  states  are  regularly  ac- 
companied by  all  sorts  of  mad  pranks,  destruction  of  property, 
adventurous  journeys,  brawls,  and  public  scandals.  When 
associated  with  expansive  ideas,  the  patients  purchase  large 
amounts  of  useless  stuff,  prepare  for  mythical  undertakings, 
and  spend  large  sums  of  money.  The  idea  that  everything 
in  their  neighborhood  belongs  to  them  induces  the  patients 
to  innocently  appropriate  whatever  they  happen  on,  to 
embezzlement,  or  to  fraud. 

Paranoiacs  systematically  prepare  their  claims,  address 
letters  to  prominent  officials,  and  publish  pamphlets.  In 
their  attempts  to  compel  notice  they  appear  on  the  street 
in  unusual  costumes,  attack  prominent  persons,  and  create 
public  scandals.  Love-letters,  proposals,  etc.,  are  directed 
at  the  supposed  secret  lover.  The  religious  paranoiac  founds 
a  church  and  seeks  a  martyr's  crown. 


METHODS   OF   EXAMINATION 

In  mental  disease  it  is  of  the  utmost  importance  that  the 
student  employ  a  definite  routine  method  of  examination  of 
the  patient.  Any  method  to  be  satisfactory  must  include 
the  (a)  anamnesis  of  the  family,  and  (b)  personal  history 
previous  to  the  disease,  (c)  the  anamnesis  of  the  disease, 
(d)  and  finally  the  status  prsesens. 

(a)  The  importance  of  heredity  as  an  etiological  factor 
necessitates  a  careful  consideration  of  the  family  history, 
not  only  as  regards  the  presence  of  mental  and  neurological 
diseases,  but  also  evidences  of  defective  physical  constitu- 
tion. This  can  never  be  elicited  by  simply  asking  the 
general  question  if  there  is  a  history  of  insanity  or  nervous 
diseases  in  the  family,  but  it  requires  a  detailed  inquiry 
into  the  habits,  traits,  and  physical  illnesses  of  all  the  mem- 
bers of  the  direct  branches  of  the  family,  laying  particular 
stress  upon  mental  peculiarities,  alcoholic  and  other  addic- 
tions, and  criminal  tendencies. 

(6)  The  personal  history  should  begin  with  an  inquiry 
into  the  conditions  attending  gestation  and  birth,  such  as, 
exhausting  diseases,  deprivation,  severe  emotional  shocks, 
mental  anguish,  and  birth  trauma.  In  infancy  there  is  the 
presence  of  infectious  diseases  and  their  sequelae,  con- 
vulsions, head  injury,  paralyses  and  the  tardy  appearance 
of  walking  and  talking,  and  in  childhood,  the  progress  in 
school  and  conditions  accompanying  puberty  and  menstrua- 
tion, also  the  existence  of  masturbation,  sexual  impulses, 
peculiar   emotional   manifestations,  timidity,  morbid  tem- 

h  97 


98  GENERAL  SYMPTOMATOLOGY 

peraments,  religious  experiences,  etc.  If  married,  the  con- 
ditions attending  child-bearing  should  be  known,  as  well  as 
severe  illnesses,  such  as,  typhoid  fever,  injuries,  mental 
shocks,  and  deprivation;  and  if  employed,  the  character  of 
the  work,  the  materials  handled,  the  sanitation  and  undue 
physical  and  mental  strain,  excessive  indulgence  in  eating, 
drinking,  and  amusement,  and  also  drug  habituation.  Per- 
sonal idiosyncrasies,  exaggerated  egotism,  one-sided  in- 
tellectual development,  with  attainments  in  one  field  and 
lack  of  development  in  another,  should  be  included  in  your 
list  of  inquiries.  In  eliciting  such  facts  it  should  be  borne  in 
mind  that  general  questions  are  wholly  inadequate.  It 
requires  close  and  detailed  questioning,  and  even  then  im- 
portant facts  are  very  apt  to  be  overlooked. 

In  determining  the  cause  of  the  disease  one  should  guard 
against  mistaking  for  causes  the  actual  early  symptoms  of 
disease;  such  as  the  excesses  of  the  paretic,  the  self-con- 
demnation of  the  melancholiac,  and  the  masturbation  of  the 
hebephrenic. 

(c)  In  eliciting  the  anamnesis  of  the  disease  particular  at- 
tention should  be  paid  to  the  character  of  the  onset  and  the 
symptoms  to  date.  In  securing  this  information  it  is  usually 
most  satisfactory  to  follow  out  the  outline  prescribed  for  mak- 
ing a  mental  status;  i.e.  elicit  information  concerning  the 
presence  of  hallucinations  or  illusions  at  various  periods,  of 
disorder  of  orientation,  attention,  memory,  train  of  thought, 
judgment,  and  in  the  emotional  and  volitional  fields. 

It  is  often  difficult  to  determine  the  actual  date  of  onset 
of  the  disease  because  the  initial  change  in  disposition  is 
sometimes  so  insidious  that  the  true  significance  of  certain 
peculiarities  is  not  appreciated  until  emphasized  later  by  the 
occurrence  of  the  more  striking  symptoms.  In  case  there 
have  been  one  or  more  previous  attacks  of  mental  disease 


METHODS  OF  EXAMINATION  99 

there  should  be  the  same  careful  inquiry  not  only  into  the 
character  of  the  symptoms  presented  at  these  periods  and 
their  duration,  but  also  particularly  as  to  whether  the  patient 
fully  recovered  or  suffered  residual  defects  in  some  field  of 
the  mental  life. 

(d)  Status  prwsens.  This  examination  should  include  ob- 
servations of  both  the  physical  and  mental  conditions  of 
the  patient.  In  view  of  the  fact  that  many  persons  are 
particularly  sensitive  about  undergoing  a  mental  examination 
it  is  desirable  to  begin  with  the  physical  examination.  Dur- 
ing it  there  is  always  opportunity  to  frame  questions  in  such 
a  way  that  the  answers  will  give  valuable  information  as 
to  the  mental  state;  as,  for  instance,  the  memory  can  be 
determined  by  questions  as  to  the  date  of  appearance  of 
certain  physical  signs,  or  the  orientation  may  be  ascertained 
by  questions  as  to  those  who  are  caring  for  them,  by  whom 
their  food  is  prepared,  etc.  Indeed,  the  great  variety  of 
physical  symptoms  to  be  inquired  into  offers  sufficient  chance 
to  cover  all  fields  of  the  mental  status;  even  hallucinations 
and  illusions  of  hearing  and  sight  may  be  disclosed  by  the 
examination  of  the  senses  of  hearing  and  sight. 

The  general  survey  of  the  body  should  include  the  state 
of  nutrition,  the  present  body  weight  compared  with  earlier 
weights,  the  presence  of  anaemia  or  cachexia,  signs  of  prema- 
ture senility,  or  delayed  pubescence,  also  evidences  of  so- 
called  physical  stigmata,  as  harelip,  malformation  of  the 
palate,  of  the  ears,  or  sexual  organs,  albinism,  congenital 
strabismus,  malposition  of  the  teeth  and  eyes,  etc.  Trauma, 
scars,  and  residuals  of  previous  diseases  should  not  be  over- 
looked, and  particularly  those  of  syphilis.  The  physical 
examination  should  be  careful  enough  to  eliminate  such 
chronic  diseases  as  chronic  nephritis,  uraemia,  diabetes, 
pernicious  anaemia,   Graves'  disease,  tuberculosis,  syphilis, 


100  GENERAL  SYMPTOMATOLOGY 

lead  poisoning,  and  chronic  gastritis.  The  condition  of 
sleep  and  of  the  gastro-intestinal  tract  needs  special  atten- 
tion because  of  the  frequency  with  which  disturbances  exist 
in  these  fields. 

In  the  examination  of  the  nervous  system,  the  measure- 
ments of  the  cranium  will  give  some  indication  as  to  the 
development  of  the  cortex,  but  it  is  of  more  importance  to 
observe  the  disproportion  between  the  cranium  and  the  rest 
of  the  body.  The  circumference  of  the  skull  taken  along 
the  line  just  above  the  external  occipital  protuberance  and 
the  glabella  should  measure  in  an  adult  between  48  and  56 
centimeters,  while  the  distance  between  the  extreme  lateral 
points  as  taken  by  craniometer  should  be  between  14  and  15 
centimeters.  The  examination  of  the  eye  grounds  should 
not  be  omitted,  as  it  often  reveals  vascular  sclerosis,  which 
might  otherwise  escape  notice.  Likewise,  a  careful  ex- 
amination of  the  ears  sometimes  discloses  a  sufficient  cause 
for  peripheral  hallucinations. 

Then  the  muscular  system  should  be  examined.  First 
determine  the  condition  of  muscular  tonicity  by  employing 
passive  movements  and  examining  the  tendon  reflexes. 
Both  of  these  may  be  difficult  on  account  of  lack  of  coopera- 
tion and  inability  to  secure  complete  relaxation  of  the  limbs ; 
hence  it  is  important  to  have  the  patients  in  a  comfortable 
and  restful  attitude,  such  as  in  a  recumbent  position,  with 
their  attention  distracted  by  engaging  them  in  conversation, 
giving  them  figures  to  add  or  something  to  read  aloud. 
In  eliciting  the  knee  jerks,  if  the  patient  is  lying  on  his  back, 
place  left  hand  beneath  the  knee  and  gently  lift  it,  allowing 
the  foot  to  rest  on  the  bed.  If  you  find  the  leg  relaxed,  strike 
the  tendon  at  any  time.  Frequently  the  patient  will  not 
relax  until  you  have  raised  the  knee  high  enough  so  that  it 
will  support  itself  in  that  position.     If  the  patient  is  sitting, 


METHODS  OF  EXAMINATION  101 

he  should  recline  backward  in  an  easy  posture,  with  both  feet 
squarely  on  the  floor  and  brought  as  far  forward  as  possible 
without  causing  the  toes  to  leave  the  floor. 

The  ankle  clonus  is  best  elicited  now  by  slipping  the  right 
hand  under  the  toes  and  sole  of  the  foot  and  quickly  jerking 
the  foot  upward  for  a  few  inches,  so  that  the  weight  of  the 
elevated  leg  and  thigh  rests  on  your  hand.  The  Achilles 
jerk  is  determined  by  asking  the  patient  to  stand  leaning 
forward  and  supporting  his  weight  by  placing  his  hands  on 
the  top  of  a  table  or  back  of  a  chair.  The  ankle  is  then 
lifted  in  the  rear  and  allowed  to  rest  on  your  knee,  when  the 
tendon  is  struck.  The  wrist  and  jaw  reflexes  should  also  be 
determined. 

The  muscles  should  be  examined  further  by  palpation  and 
by  the  exercise  of  active  movements  which  will  determine  the 
presence  of  paralysis  (flaccid,  spastic,  or  accompanied  by 
contractures),  as  well  as  disturbances  of  coordination.  Such 
movements  are  the  voluntary  raising  of  the  legs  while  the 
patient  is  recumbent,  attempts  to  touch  the  knee,  to  touch 
the  end  of  the  nose  with  the  forefinger  with  or  without 
closed  eyes,  standing  erect  with  eyes  closed  and  feet  close 
together,  closing  the  eyes,  opening  the  mouth,  and  protruding 
the  tongue  upon  command,  and  then  reversing  the  order. 
These  tests  should  also  include  voluntary  writing,  and  speech, 
as  well  as  the  enunciation  of  different  words,  such  as  "electric- 
ity," "Massachusetts  artillery  brigade,"  "around  the  rugged 
rock  the  ragged  rascal  ran."  The  movements  employed 
above  will  also  demonstrate  tremors  (fine,  coarse,  fibrillary, 
and  retractile  of  the  tongue),  which  should  be  noted. 

The  mechanical  irritability  of  the  muscles  and  the  nerves 
is  then  determined  by  percussion  of  the  muscles,  and  the 
mechanical  stimulation  of  the  peripheral  nerves.  The  nature 
of  spasms  should  also  be  investigated  (epileptic,  hysterical, 


102  GENERAL  SYMPTOMATOLOGY 

choreic,  and  athetoid).  Finally,  the  irritability  of  the  muscles 
and  nerves  to  electricity,  wherever  there  are  indications  for 
its  use,  should  be  determined,  since  disturbances  in  it  as 
well  as  in  all  of  these  other  fields  may  have  distinct  bearing 
upon  the  general  brain  condition. 

Following  this  the  sensibility  should  be  tested,  including 
the  sensations  of  pain,  touch,  and  temperature,  for  areas  of 
hyperesthesia,  analgesia,  and  paresthesia.  For  this  pur- 
pose the  simplest  implements  are  the  best;  namely,  a  camel' s- 
hair  brush,  a  needle,  and  small  bottles  of  hot  and  cold  water. 
It  may  also  be  necessary  to  examine  the  stereognostic  sense. 

Vasomotor,  secretory,  and  trophic  disorders  should  be 
recognized  and  recorded,  particularly  cyanosis  of  the  extremi- 
ties, dermography,  glossy  skin,  canities,  alopecia,  ony- 
chogryphosis,  naevi,  herpes,  scleroderma,  and  hyperidrosis ; 
the  various  trophic  disorders  of  the  bones  and  joints,  includ- 
ing spontaneous  fractures  and  hsemotama  auris. 

In  the  examination  of  the  pulse  there  is  nothing  to  be 
found  peculiarly  characteristic  of  any  special  form  of  mental 
disease.  The  blood  pressure  in  fearful  and  depressive 
states  is  usually  elevated,  and  depressed  in  manic  states, 
corresponding  with  the  vasomotor  symptoms  ordinarily 
accompanying  these  states.  The  fall  in  blood  pressure 
observed  in  the  end  stages  of  paresis  is  in  accord  with  the 
progressive  terminal  cardiac  weakness.  The  examination 
of  the  blood  has  been  thus  far  unproductive  of  characteristic 
disorders.  In  any  given  psychosis  the  blood  states  may 
vary  considerably  in  the  different  stages.  In  the  psychoses 
studied  by  us l — dementia  precox,  manic-depressive  insanity, 

1  "Blood  Changes  in  Dementia  Paralytica,"  American  Journal  of  Med. 
Soc,  Vol.  126,  p.  1074. 

"A  Contribution  to  the  Study  of  Blood  in  Manic  Depressive  Insanity," 
American  Journal  of  Insanity,  LIX,  No.  4,  1903. 


METHODS  OF  EXAMINATION  103 

and  dementia  paralytica  —  the  only  apparently  character- 
istic blood  states  were  those  found  in  dementia  paralytica, 
where  there  was  a  progressive  anaemia  and  a  progressive 
increase  of  polymorphonuclear  leucocytes  accompanying 
the  advancing  course  of  the  disease  and  the  presence  of  a 
leucocytosis  accompanying  paralytic  attacks.  The  chemical 
investigations  of  the  urine,  gastric  contents,  and  of  body 
metabolism,  while  still  fruitful  fields  for  study,  do  not  warrant 
routine  examinations  except  in  the  matter  of  urine  and  gastric 
contents  to  obtain  indications  for  treatment. 

A  careful  physical  examination  should  include  in  doubtful 
cases  the  examination  of  the  cerebrospinal  fluid  for  the  pur- 
pose of  differentiating  between  functional  or  organic  dis- 
eases. As  much  depends  upon  the  technique,  the  method 
is  briefly  stated.  With  the  strictest  aseptic  precautions  the 
needle  is  inserted  between  the  fourth  and  fifth  lumbar 
vertebrae,  and  three  or  four  centimeters  of  fluid  withdrawn. 
This  is  immediately  centrifugalized  10  minutes  —  if  the 
speed  is  3000  revolutions,  or  30  minutes  —  if  only  2500  revo- 
lutions can  be  obtained.  The  supernatant  fluid  is  poured 
out  of  the  glass  and  then  a  pipette  is  carefully  introduced  into 
the  bottom  of  the  tube  and  the  sediment  all  withdrawn. 
This  is  thoroughly  mixed  by  blowing  it  out  into  the  tube  and 
sucking  it  up  again,  when  three  drops  of  equal  size  are 
dropped  on  three  slides,  which  are  allowed  to  dry  in  the  air. 
The  slides  are  fixed  by  a  half-hour  immersion  in  equal  parts 
of  absolute  alcohol  and  ether,  stained  with  a  few  drops  of 
Unna's  polychrome  methylene  blue,  washed  in  water, 
then  in  alcohol,  cleared  in  xylol,  and  mounted  in  balsam. 
With  a  magnification  of  300  to  400  times  the  presence  of  three 
or  four  lymphocytes  in  a  single  field  may  be  regarded  as 
normal.  At  least  three  lumbar  punctures  are  necessary 
for  a  final  decision.    The  bacteriological  examination  of  the 


104  GENERAL  SYMPTOMATOLOGY 

cerebrospinal  fluid  as  well  as  of  the  blood  has  thus  far  yielded 
such  varying  results  in  the  hands  of  different  observers  that 
a  routine  examination  cannot  be  recommended  for  diag- 
nostic purposes. 

The  most  difficult  part  of  the  examination  is  securing  the 
mental  status.  In  this  matter  much  depends  upon  the 
acuteness  of  the  observer,  as  the  patient  often  enough  cannot 
be  depended  upon  for  cooperation.  Unfortunately,  we  have 
no  scientific  standards  for  determining  the  mental  symptoms, 
but  must  depend  upon  the  simplest  psychological  tests; 
namely,  the  asking  of  questions. 

For  convenience  and  thoroughness  of  examination  it  is 
most  important  to  always  have  before  one  an  outline  of  the 
method  of  examination.  If  for  purposes  of  record  or  other- 
wise, and  particularly  in  medico-legal  cases,  it  is  necessary 
to  write  down  the  observations,  it  is  always  best  to  write  in 
full  the  question  and  the  answer  verbatim  as  given  by  the 
patient.  Upon  subsequent  examinations  the  same  questions 
should  be  asked,  and  the  answers  compared.  The  general 
arrangement  of  this  outline  should  follow  closely  the 
presentation  of  the  general  symptomatology;  i.e.  disturb- 
ances of  perception,  clouding  of  consciousness,  disturbances 
of  apprehension,  of  attention,  of  memory,  of  orientation,  of  the 
train  of  thought,  of  judgment,  of  the  emotions,  and  of  the  voli- 
tions. 

1.  Disturbances  of  Perception  (hallucinations  and  illu- 
sions).—  Hallucinations  can  oftentimes  be  most  readily 
elicited  by  asking  the  patient  directly  if  he  hears  voices  or 
sees  pictures  or  visions,  or,  if  this  question  is  not  understood, 
if  he  hears  noises  or  voices  when  no  one  is  about  him.  Fre- 
quently the  patient  does  not  consider  the  hallucinations  as  a 
peculiar  sensory  experience  and  will  answer  your  questions 
negatively.     Then  he  should  be  questioned  closely  as  to 


METHODS  OF  EXAMINATION  105 

how  he  sleeps  nights,  and  whether  or  not  he  is  disturbed. 
Again,  he  may  be  questioned  as  to  whether  or  not  intimate 
associates,  shopmates,  employers,  or  business  associates, 
whom  you  know  to  be  absent,  converse  with  him.  Such 
questions  often  elicit  the  desired  evidence  of  hallucinations. 
Sometimes  sense  deceptions  are  elicited  only  when  one  seeks 
for  the  basis  of  certain  delusions  held  by  the  patient,  when, 
for  instance,  he  will  admit  that  he  believes  he  is  persecuted 
because  of  remarks  that  he  hears.  Patients  observed 
assuming  listening  attitudes  and  addressing  remarks  to 
unseen  persons,  or  gesticulating  earnestly  in  a  definite 
direction,  or  persistently  spitting  out  or  casting  aside  good 
food  without  adequate  reason,  may  be  regarded  as  suffering 
from  sense  deceptions,  although  these  are  denied  by  them 
when  questioned  directly.  In  the  matter  of  religious 
hallucinations,  such  as  the  voice  of  God,  one  should  be 
particularly  careful  not  to  mistake  the  "  voice  of  conscience  " 
or  the  "  voice  of  the  heart  "  as  genuine  hallucinations,  a 
distinction  which  some  patients  are  loath  to  admit.  Again, 
sometimes  what  in  many  appear  to  be  true  hallucinations 
are  not  such,  but  are  really  genuine  perceptions.  In  this 
matter  one  cannot  exercise  too  great  care.  What  has  been 
indicated  in  reference  to  hallucinations  and  illusions  of  sight 
and  hearing  refers  equally  well  to  the  hallucinations  and 
illusions  of  the  other  senses. 

2.  Clouding  of  Consciousness  and  Disturbances  of  Ap- 
prehension. —  The  determination  of  unconsciousness,  of 
befogged  states,  and  of  diminished  sensibility  depends  mostly 
in  clinical  practice  upon  the  patient's  reaction  to  definite 
stimuli,  such  as  one  uses  in  any  neurological  examination ; 
namely,  the  test  of  pain  and  touch  sense  by  the  use  of  the 
needle,  of  hearing  by  the  use  of  speech,  of  sight  by  writing 
tests  or  the  perception  of  colors.    Further,  the  compre- 


106  GENERAL  SYMPTOMATOLOGY 

hension  of  simple  or  confused  pictures  (medleys)  placed 
before  the  patients  gives  an  insight  into  these  defects. 
Many  elaborate  tests,  such  as  Hipp's  chronoscope  and  the  ap- 
paratus of  Ranschburg,  have  been  devised  for  the  accurate 
determination  of  the  process  of  perception,  which  are  not 
wholly  suitable  for  general  application  or  for  bedside  use. 

3.  The  Disturbances  of  Attention  (blunting,  blocking, 
retardation,  passivity,  and  distractibility)  can  usually  be 
determined  in  a  satisfactory  manner  by  the  use  of  the  pro- 
gressive adding  and  subtracting  test,  such  as,  subtracting 
7  successively  from  100  down  to  0.  The  variations  in  the 
rapidity  and  the  occasional  blocking  afford  good  demonstra- 
tions of  the  stability  of  the  attention.  The  introduction 
of  distracting  influences  during  the  test,  such  as  dropping  a 
cent  upon  the  floor,  will  bring  out  distractibility  of  attention. 
In  the  application  of  such  a  test  one  must  always  take  into 
account  the  social  grade  of  the  individual  as  well  as  the  degree 
of  his  education. 

4.  Memory  (defects  in  the  impressibility,  retentiveness, 
accuracy,  and  fabrications  of  memory). — The  retentiveness 
of  memory  is  usually  determined  by  a  series  of  questions 
directed  toward  the  retention  of  certain  school  knowledge, 
such  as  the  multiplication  table ;  or  the  uninterrupted  adding 
or  subtracting  of  3,  7,  or  12,  the  time  required  being  measured 
by  a  stop-watch.  The  retentiveness  in  patients  sensitive 
to  being  subjected  to  such  tests  can  be  estimated  only  by 
asking  questions  concerning  the  past  personal  experiences  or 
facts  in  history. 

The  impressibility  of  memory  can  be  most  readily  de- 
termined by  asking  the  patient  to  repeat  numbers  of  more 
than  one  figure  which  are  dictated  to  him ;  also  unfamiliar 
combinations  of  syllables.  This  may  be  done  both  orally 
and  by  writing.    Again,  he  may  be  asked  to  recognize  in  a 


METHODS  OF  EXAMINATION  107 

group  of  pictures  a  certain  picture  which  has  previously 
been  shown  to  him.  Questions  directed  to  ascertaining 
recent  occurrences  in  their  daily  lives,  such  as  what  he  had 
for  dinner  yesterday,  what  the  nurse  or  doctor  is  doing  for 
him,  may  be  asked.  In  the  determination  of  both  the 
retentiveness  and  impressibility  one  must  never  demand 
from  an  uneducated  person  more  than  he  ever  acquired. 
The  accuracy  of  memory  and  the  fabrications  will  already 
have  been  elicited  by  the  questions  asked  in  reference  to 
remote  and  recent  personal  experiences. 

5.  Orientation  (apathetic,  amnesic,  and  delusional  dis- 
orientation and  perplexity). — The  orientation  as  to  time, 
place,  and  persons  is  determined  by  such  questions  as: 
"  What  is  the  date  of  the  month,  the  day  of  the  week,  and 
the  season  and  year?  "  "  Where  are  you  now?  "  "  What 
is  the  name  of  the  place,  of  the  building  and  its  character,  and 
of  the  city?  "  "  Who  are  these  persons  about  you,  their 
duty  here,  and  what  is  your  mission  here?  "  In  case  the 
patient  is  not  disposed  to  or  is  unable  to  respond,  his  orienta- 
tion as  well  as  his  power  of  apprehension  can  be  determined 
by  watching  carefully  his  conduct  in  his  environment; 
for  instance,  noting  the  names  with  which  he  addresses  his 
associates,  his  religious  observances,  his  ability  to  find  his 
way  about  in  familiar  environment,  etc. 

6.  Train  of  Thought  (paralysis  of  thought,  retardation 
of  thought,  compulsive  ideas,  simple  persistent  ideas,  per- 
severation, circumstantiality,  flight  of  ideas,  desultoriness). — 
If  the  patient  is  at  all  communicative  and  has  answered  the 
foregoing  questions,  you  already  have  had  some  opportunity 
to  judge  of  the  wealth  of  his  store  of  ideas,  or  the  degree  of 
its  impoverishment,  if  present ;  also  to  some  extent  of  all  of  the 
other  disturbances  of  the  train  of  thought,  and  particularly 
the  retardation  of  thought.    If  the  patient  is  productive 


108  GENERAL  SYMPTOMATOLOGY 

and  volunteers  much  speech,  there  is  usually  little  difficulty 
in  determining  the  presence  of  simple  persistent  ideas,  cir- 
cumstantiality, flight  of  ideas,  and  desultoriness.  In  case 
the  patient  is  not  productive,  the  disturbances  in  the  content 
of  thought  can  be  elicited  by  requesting  him  to  recite 
connectedly  the  incidents  of  some  recent  personal  experience ; 
such  as  the  detailed  account  of  the  nurse's  method  of  caring 
for  him  or  the  account  of  the  journey  to  the  hospital.  It 
may  be  necessary  in  order  to  keep  the  patient  talking  to  con- 
tinually urge  him  by  interjecting  "  Yes,  yes,"  or,  "  Is  that 
so?  "  In  this  way  circumstantiality,  flight  of  ideas,  and 
desultoriness  is  usually  detected.  Another  method  is  to 
peruse  the  voluntary  writings  of  the  patient,  particularly 
home  letters. 

There  are  many  more  accurate  tests  for  determining  the 
associations  of  ideas.  Of  these,  the  one  most  easily  carried 
out  at  the  bedside  is  to  give  the  patient  any  sort  of  a  word, 
such  as  "horse,"  and  then  ask  him  to  speak  aloud  the  ideas 
first  arising  in  his  mind,  which  you  may  write  down,  or  you 
may  ask  the  patient  himself  to  write  down  all  ideas  occurring 
to  him  in  a  definite  period  of  time  after  being  given  the  initial 
word.  In  this  way  one  can  obtain  some  conception  of  the 
relationship  between  the  inner  and  external  associations,  of 
the  prominence  and  frequency  of  fixed  associations,  senseless 
and  sound  associations,  of  uniformity  and  the  desultoriness 
of  the  train  of  thought,  as  well  as  the  wealth  of  the  store  of 
ideas,  the  tendencies  to  sudden  cessations,  or  the  tenacious 
holding  of  a  single  idea. 

7.  Judgment  (delusions).  —  Usually  by  the  time  one 
has  reached  this  stage  of  the  examination  real  delusions 
have  been  actually  expressed  or  some  hints  have  been  acci- 
dentally dropped  which  will  serve  as  a  basis  for  further 
questioning.      In   determining   delusions,  direct   questions 


METHODS  OF  EXAMINATION  109 

are  less  pernicious  than  in  eliciting  some  of  the  other  mental 
symptoms.  One  may  ask  the  patient  if  he  is  troubled  in 
any  way,  if  the  affairs  at  home  are  moving  smoothly,  if 
his  business  is  successful,  and  if  he  is  at  all  apprehensive 
of  his  welfare,  etc.  Should  your  patient  show  considerable 
reserve  and  refuse  to  speak  of  personal  matters,  as  often 
happens  immediately  after  his  liberty  is  restrained  or  he  is 
placed  in  a  new  environment,  one  must  be  tactful  in  approach- 
ing the  matter  of  delusions.  Sometimes  the  simple  direct 
question  as  to  why  he  has  been  deprived  of  his  liberty  or 
submitted  to  the  care  of  the  physician  may  be  sufficient. 
Again,  it  may  be  necessary  to  introduce  a  subject  of  much 
interest  to  him,  such  as  his  employment,  literature,  or  travel- 
ling, or  he  may  be  asked  to  express  his  judgment  as  to  cost 
of  manufacture  of  the  material  with  which  he  works,  the 
contentions  of  trade  unions,  the  utility  of  trusts,  or  his 
opinion  of  the  countries  in  which  he  may  have  travelled.  A 
free  discussion  of  a  matter  of  general  interest,  but  at  the  same 
time  bearing  upon  the  individual's  livelihood,  usually  un- 
covers some  of  his  delusions,  if  any  be  present.  In  the  case 
of  women,  domestic  difficulties,  church  or  social  relations, 
and  especially  neighborhood  differences,  are  usually  fruitful 
sources  for  discussion  and  inquiry.  The  various  somatic 
delusions  are  most  often  brought  out  by  questions  as  to  the 
health  of  all  the  various  organs  of  the  body.  The  evidence 
of  systematization  of  delusions  can  often  be  best  determined 
by  asking  directly,  "  What  is  the  object  of  all  this?  "  or, 
"  Do  these  various  ideas  bear  any  relation  to  each  other  ?  " 

Defective  judgment  in  other  matters  than  delusions  will 
usually  be  established  by  such  general  discussions  as  those 
advised  above  or  by  such  questions  as,  "  What  do  you  think 
of  the  restriction  of  your  liberty?  "  "  How  much  does  it 
cost  you  to  live  ?  "    "Are  you  receiving  sufficient  wages,  and 


110  GENERAL  SYMPTOMATOLOGY 

do  you  live  within  your  income?  "  "  Figure  up  your  cost 
of  living."  "  Who  aids  in  the  support  of  your  family,  and 
do  they  do  as  much  as  they  should?  "  etc. 

8.  Emotional  Field  (emotional  deterioration,  increase 
of  emotional  irritability,  sad  disposition,  irritable  disposition, 
seclusiveness,  sunny  disposition,  fanaticism,  morbid  frivolity, 
fear,  phobias,  dejection,  sadness,  feelings  of  pleasure,  feeling 
of  well-being,  disturbances  of  hunger,  nausea,  pain,  and  of 
the  sexual  feelings.)  —  In  this  field  one  has  to  depend  rather 
more  upon  observation  than  upon  interrogation  of  the 
patient,  as  there  is  large  opportunity  for  simulation  and 
falsehood.  Most  patients  if  asked  if  they  loved  their  par- 
ents would  say  "  Yes  "  even  though  they  might  be  totally 
barren  of  all  affection  and  exhibiting  profound  emotional 
deterioration.  One  rather  has  to  rely  upon  the  observa- 
tions of  others  as  to  relations  which  the  patient  maintains 
with  his  family,  in  his  work,  and  in  his  social  environment, 
which  would  exhibit  increased  and  diminished  emotional 
irritability  and  persistent  sadness  or  elation.  Likewise  one 
cannot  depend  upon  the  patient  for  accurate  observations 
as  to  whether  or  not  he  is  of  a  sad,  sunny,  seclusive,  or  irri- 
table disposition,  or  given  to  fanaticism  or  morbid  frivolity. 
The  persistent  feelings  of  fear,  of  sadness,  and  of  well-being 
usually  become  apparent  to  one  during  a  prolonged  examina- 
tion and  do  not  need  special  inquiry.  Yet  in  this  matter 
one  sometimes  must  ask  the  patient  directly  how  he  feels, 
or  whether  or  not  he  is  fearful  or  dejected.  The  disturbances 
of  the  general  feelings  of  pain,  of  hunger,  nausea,  and  of 
the  sexual  life  are  more  readily  determined  by  observation 
of  the  conduct  than  by  questioning. 

In  questioning  those  most  intimately  associated  with  the 
patient  one  may  ask  such  questions  as  these :  whether  or  not 
there  has  been  a  change  of  disposition;   previous  to  illness 


METHODS  OF  EXAMINATION  111 

was  the  individual  of  a  sociable,  cheery,  or  melancholy  dispo- 
sition; was  he  fond  of  solitude,  was  he  silent,  timid,  coura- 
geous, irascible,  suspicious,  or  proud  and  egotistical;  is  he 
now  fond  of  his  family  or  apathetic,  is  he  fulfilling  his  family 
and  business  obligations,  or  is  he  negligent,  disrespectful, 
or  insensible  to  the  feelings  and  interests  of  others;  is  he 
fulfilling  his  religious  obligations,  or  does  his  general  conduct 
show  unnatural  fear,  sadness,  or  exaltation. 

We  have  at  best  no  very  accurate  means  of  measuring  the 
emotional  side  of  the  life  of  the  patient.  Feelings  of  dis- 
pleasure, of  pain,  fear,  and  anger  can  be  created  experi- 
mentally in  various  ways  and  by  hypnosis,  and  the  latter 
method  has  been  employed  by  Lehmann  to  determine  the 
influence  of  emotional  states  upon  respiration,  pulse  rate, 
and  blood  pressure.  Furthermore,  the  writing  scale  and  the 
ergograph,  which  are  used  to  measure  the  finer  expressions 
of  the  will,  are  serviceable  in  measuring  the  outward  expres- 
sions of  emotional  excitement. 

9.  Volitional  Field  (paralysis  of  the  will,  pressure  of 
activity,  psychomotor  retardation,  stupor,  blocking  of  the 
will,  muscular  tension,  hypersuggestibility  of  the  will,  catalepsy, 
cerea  flexibilitas,  exhopraxia,  distractibility  of  the  will,  inter- 
ference, stereotypy,  mannerisms,  negativism).  —  Here  also 
one  must  depend  to  a  large  degree  upon  observation  of  the 
conduct,  both  spontaneous  and  in  obedience  to  command  or 
suggestion.  Thus  paralysis  of  the  will  can  be  determined 
by  watching  the  patient's  voluntary  movements,  also  the 
reaction  in  response  to  the  call  to  dinner  or  when  requested 
to  attend  some  simple  duty.  Pressure  of  activity,  retarda- 
tion, stupor,  and  blocking  of  the  will,  as  well  as  muscular 
tension,  are  usually  evinced  before  one  has  reached  this  stage 
of  the  examination.  The  methods  of  physical  examination 
are  sure  to  bring  out  these  defects  as  well  as  cerea  flexibilitas 


112  GENERAL  SYMPTOMATOLOGY 

and  catalepsy.  If  not,  one  has  simply  to  grasp  the  arm  and 
place  it  in  an  awkward  and  uncomfortable  position  or  to 
command  the  patient  to  perform  certain  movements,  as 
walking,  shaking  hands,  or  writing.  If  negativism  is  pres- 
ent, it  also  will  be  elicited  by  these  methods.  Distrac- 
tibility  of  the  will,  interference,  stereotypy,  and  mannerisms 
are  elicited  by  similar  commands. 

The  observation  of  the  conduct  by  nurses  and  others 
should  be  inquired  into,  as  in  this  way  the  varying  periods 
of  mutism,  negativism,  muscular  tension,  and  tendency  to 
eat  the  food  of  others  and  to  get  into  others'  beds,  to  stand 
in  awkward  and  statuesque  positions,  can  be  elicited,  which 
may  not  be  present  at  the  time  of  your  examination. 

In  the  finer  analysis  of  disturbances  of  volition,  partic- 
ularly psychomotor  excitement,  retardation,  and  tension, 
Kraepelin  suggests  the  writing  scale,  by  which  one  can  de- 
termine the  path  of  the  writing,  the  rapidity,  and  the  press- 
ure. Also  the  ergograph,  invented  by  Mosso,  can  be  em- 
ployed to  measure  the  strength  of  the  movement,  the  effect 
of  retardation,  fatigue,  and  muscular  tension,  as  well  as 
the  rapidity  with  which  the  contraction  and  relaxation  of  the 
muscles  follow  under  the  influence  of  the  impulses  of  the 
will.  Both  of  these  instruments,  however,  have  their 
drawbacks  which  render  their  routine  application  unsatis- 
factory. The  more  severe  disturbances  in  the  release  of  the 
volitional  impulses  can  be  measured  by  the  use  of  the  watch, 
such  as  in  counting  as  rapidly  as  possible  from  1  to  30, 
rapidly  repeating  the  alphabet,  or  in  simply  raising  the  arm. 


FOEMS   OF   MENTAL  DISEASES 


CLASSIFICATION  OF  MENTAL  DISEASES 

CONSIDERATION  OF  THE  FACTORS  ENTERING  INTO 
A  PROVISIONAL  CLASSIFICATION 

The  principle  requisite  in  the  knowledge  of  mental  diseases 
is  an  accurate  definition  of  the  separate  disease  processes. 
In  the  solution  of  this  problem  one  must  have,  on  the  one 
hand,  knowledge  of  the  physical  changes  in  the  cerebral 
cortex,  and  on  the  other  of  the  mental  symptoms  associated 
with  them.  Until  this  is  known  we  cannot  hope  to  under- 
stand the  relationship  between  mental  symptoms  of  disease 
and  the  morbid  physical  processes  underlying  them,  or  in- 
deed the  causes  of  the  entire  disease  process.  There  are 
still  other  difficulties  to  be  encountered  in  obtaining  that 
fundamental  knowledge  necessary  for  a  scientific  classifi- 
cation of  mental  diseases.  In  the  first  place,  it  is  almost 
impossible  to  establish  a  fundamental  distinction  between 
the  normal  and  the  morbid  mental  state,  as  was  frequently 
indicated  in  our  discussion  of  the  general  symptomatology. 
It  is  equally  difficult  sometimes  to  distinguish  between  the 
transition  states  existing  between  different  forms  of  recog- 
nized types  of  mental  disease.  Again,  the  symptoms  of  the 
disease  are  apt  to  be  greatly  influenced  and  exaggerated  by 
the  morbid  hereditary  basis  which  underlies  so  many  forms 
of  mental  disease.  Finally,  as  the  functions  of  different 
parts  of  the  brain  differ,  hence  the  character,  intensity,  and 
location  of  the  morbid  process  influence  greatly  the  grada- 
tions in  the  form  of  the  mental  disease. 

115 


116  FORMS  OF  MENTAL  DISEASES 

Clearly,  then,  there  is  at  present  no  sure  foundation  upon 
which  to  construct  a  final  standard  classification.  Never- 
theless, there  is  always  a  demand  for  some  grouping  of  our 
knowledge  as  a  basis  for  practical  work,  particularly  in 
teaching.  Judging  from  experience  in  internal  medicine, 
the  safest  foundation  for  a  classification  of  this  kind  is  that 
offered  by  pathological  anatomy.  Unfortunately,  however, 
mental  diseases  thus  far  present  but  very  few  lesions  that 
have  positively  distinctive  characteristics,  and  furthermore 
there  is  the  extreme  difficulty  of  correlating  physical  and 
mental  morbid  processes. 

Likewise  it  has  been  impossible  thus  far  to  establish  a 
classification  upon  an  etiological  basis.  Although  there  are 
some  agents  that  produce  very  definite  symptoms,  such 
as  alcoholic  intoxication,  certain  acute  infectious  diseases, 
head  injury,  and  particularly  the  more  profound  types  of 
hereditary  degeneracy,  yet  very  many  individual  cases  of  in- 
sanity are  wholly  without  any  distinctive  etiological  factors. 
And  furthermore,  one  often  has  to  admit  that  any  single 
pathogenic  factor  may  make  itself  known  by  a  great  variety 
of  symptoms.  Again,  the  causes  of  mental  disease  often 
work  in  conjunction  with  each  other,  rendering  it  extremely 
difficult  to  ascertain  the  relationship  between  the  causes  and 
the  symptoms. 

The  most  popular  method  of  classifying  mental  diseases 
has  been  the  so-called  clinical  classification.  The  grave 
defect  here  arises  from  the  fact  that  there  is  apt  to  be  an 
overvaluation  of  some  symptoms  resulting  in  the  accumu- 
lation in  one  group  of  all  cases  having  in  common  some  one 
striking  symptom.  In  this  way  all  sad  and  anxious  emo- 
tional states  came  to  be  regarded  as  melancholia,  all  excited 
states  as  mania,  and  delusional  states  accompanied  by  hal- 
lucinations as  paranoia.    The  difficulty  becomes  apparent 


CLASSIFICATION  OF  MENTAL    DISEASES  117 

when  a  single  case  thus  classified  presents  during  its  course 
the  characteristics  of  several  groups.  It  is,  therefore,  essen- 
tial, as  was  pointed  out  by  Kahlbaum,  to  distinguish  be- 
tween transitory  mental  states  and  the  disease  form  itself. 
The  scientific  conception  of  the  disease  demands  knowledge 
not  only  of  the  present  state,  but  also  of  the  entire  course 
of  the  disease. 

Judging  from  our  experience  in  internal  medicine  it  is  a 
fair  assumption  that  similar  disease  processes  will  produce 
identical  symptom  pictures,  identical  pathological  anatomy, 
and  an  identical  etiology.  If,  therefore,  we  possessed  a 
comprehensive  knowledge  of  any  one  of  these  three  fields,  — 
pathological  anatomy,  symptomatology,  or  etiology,  —  we 
would  at  once  have  a  uniform  and  standard  classification 
of  mental  diseases.  A  similar  comprehensive  knowledge  of 
either  of  the  other  two  fields  would  give  not  only  just  as 
uniform  and  standard  classifications,  but  all  of  these  classi- 
fications would  exactly  coincide.  Cases  of  mental  disease 
originating  in  the  same  causes  must  also  present  the  same 
symptoms,  and  the  same  pathological  findings.  In  ac- 
cordance with  this  principle,  it  follows  that  a  clinical  group- 
ing of  psychoses  must  be  founded  equally  upon  all  three 
of  these  factors,  to  which  should  be  added  the  experience 
derived  from  the  observation  of  the  course,  outcome,  and 
treatment  of  the  disease. 

In  the  classification  presented  here  there  are  treated  first 
of  all  those  forms  of  insanity  that  are  produced  by  external 
causes;  namely,  those  psychoses  that  arise  in  connection 
with  infectious  diseases,  those  that  follow  upon  severe  ex- 
haustion, and  finally  those  produced  by  intoxicating  agencies. 
Next  are  considered  the  psychoses  presumed  to  bear  some 
relation  to  the  products  of  faulty  metabolism  and  auto- 
intoxication.    Our  knowledge  of  these  is  definite  only  in 


118  FORMS  OF  MENTAL  DISEASES 

reference  to  thyrogenous  insanity;  but  there  are  certain 
points  of  similarity  which  would  indicate  that  dementia  prae- 
cox  and  dementia  paralytica  should  also  be  classed  here. 

The  forms  of  insanity  arising  from  diseases  of  the  brain, 
the  organic  dementias,  comprise  the  next  group.  Here  ex- 
ternal causes  also  play  some  role,  as,  for  instance,  the 
syphilitic  lesions,  head  injury,  and  cerebral  embolism.  Next 
come  the  insanities  associated  with  the  involutional  period : 
melancholia  of  involution,  senile  dementia,  and  the  presenile 
state  with  delusions  of  prejudice. 

The  next  group  comprises  manic-depressive  insanity  in 
which  a  morbid  constitutional  basis  occupies  a  prominent 
position.  The  same  condition  obtains  to  a  still  more  marked 
degree  in  that  gradual  morbid  transformation  of  the  entire 
psychical  personality  designated  paranoia,  which  is  described 
next. 

In  epileptic  insanity,  which  comes  next,  besides  the 
prominent  morbid  constitutional  basis,  there  often  exist 
other  morbid  conditions  as  head  injury,  arteriosclerosis,  and 
infectious  diseases.  The  epileptic  attacks  sometimes  date 
from  some  particular  revolution  in  the  physical  organization. 
These  facts  give  to  epilepsy  an  intermediate  position  be- 
tween auto-intoxication,  organic  brain  disease,  and  heredi- 
tary mental  diseases.  We  do  not,  however,  believe  that 
the  disease  group  recognized  to-day  as  epilepsy  presents  a 
clinical  unity.  Further  knowledge  probably  will  disclose  in 
it  several  different  disease  processes.  In  hysteria,  while  the 
faulty  constitutional  basis  is  prevalent,  the  various  forms  of 
mental  disorder  seem  to  be  released  wholly  through  the 
action  of  the  emotions. 

Closely  associated  with  hysteria  are  the  insanities  of  de- 
generacy. The  morbid  constitutional  basis  encountered  here 
varies  greatly  and  it  is  often  impossible  to  differentiate  the 


CLASSIFICATION   OF  MENTAL  DISEASES  119 

several  different  forms  of  psychosis.  Yet  one  may  formulate 
two  large  groups ;  namely,  the  constitutional  psychopathic 
states  and  the  psychopathic  personalities.  The  former  com- 
prise those  morbid  constitutional  states  which  are  recognized 
by  being  more  circumscribed,  as  developing  gradually  at  first, 
or  as  appearing  only  at  times;  the  latter  include  the  charac- 
teristic morbid  developmental  forms  of  the  entire  psychic 
personality,  which  are  justly  regarded  as  an  expression  of 
degeneracy.     In  some  instances  this  division  is  inadequate. 

Finally  there  are  described  those  forms  which  indicate  a 
restriction  of  mental  development  —  an  incomplete  develop- 
ment of  the  psychical  personality.  Sometimes  the  basis  for 
this  lies  in  a  faulty  development  of  the  body,  but  more  often 
there  exist  in  the  undeveloped  brain  disease  processes,  which 
produce  a  partial  destruction  of  the  tissue,  thereby  render- 
ing mental  development  impossible.  Strictly  speaking,  these 
latter  cases  should  be  regarded  as  organic  brain  diseases. 
We  are  not  yet  in  a  position  to  distinguish  accurately 
between  restricted  development  and  diseases  of  the  brain, 
and  furthermore,  the  mark  of  congenital  weakness  pre- 
dominates to  such  a  marked  degree  in  the  clinical  pictures 
that  any  distinction  between  both  of  these  groups  which 
are  so  intimately  related  from  an  etiological  standpoint 
hardly  commends  itself.  Indeed,  we  might  go  even  a  step 
farther  and  consider  these  forms  of  defective  development 
as  states  of  mental  weakness  which  were  produced  by 
profound  mental  disease  in  the  earliest  stages  of  develop- 
ment. Also  in  these  cases  the  development  of  psychical 
personality  was  destroyed  at  the  outset. 

In  concluding  the  subject  it  should  be  emphasized  that 
many  of  the  disease  pictures  differentiated  in  the  following 
pages  are  but  attempts  to  present  a  part  of  our  observa- 
tions in  a  form  suitable  for  teaching  purposes.     It  must  be 


120  FORMS  OF  MENTAL   DISEASES 

admitted  that  even  to-day  it  is  impossible,  in  spite  of  honest 
efforts,  to  create  a  "system"  of  psychiatry  that  will  include 
all  cases.  Attempts  of  this  sort  that  have  been  made  only 
bring  confusion.  While  this  assertion  may  prove  somewhat 
disquieting  to  the  student,  to  the  investigator  it  means  a 
frank  acknowledgment  of  real  conditions  and  an  honest 
effort  to  establish  accurate  and  fundamental  knowledge 
from  our  clinical  experience. 


I.    INFECTION  PSYCHOSES 

The  mental  disturbances  here  described  are  supposed 
to  develop  primarily  from  toxins  of  infectious  diseases. 

They  are  fever  delirium,  infection  deliria,  and  post-febrile 
psychoses. 

Fever  delirium  follows  rather  closely  the  clinical  course 
of  the  fever,  and  in  a  measure  depends  upon  it.  The 
infection  delirium  corresponds  to  the  initial  deliria  of  other 
authors,  appearing  at,  or  near,  the  onset  of  infectious  dis- 
eases, independently  of  fever.  The  remaining  group  includes 
the  various  forms  of  mental  disturbance  which  follow  the 
infectious  disease,  developing  during  or  following  the  fever, 
and  which  are  apt  to  lead  to  permanent  mental  enfeeblement. 
Other  writers  describe  these  under  the  various  diseases 
which  they  accompany;  as,  typhoid  delirium,  pneumonic 
delirium,  influenza  insanity,  and  insanities  following  ex- 
anthemata. The  mental  symptoms  arising  from  the  toxins 
of  the  different  infectious  diseases  cannot  as  yet  be  suffi- 
ciently differentiated  to  permit  of  their  being  considered 
as  characteristic  of  the  corresponding  disease.  The  only 
distinguishing  features  are  the  physical  symptoms  character- 
istic of  the  different  diseases.  It  is  still  a  question  whether 
the  changes  in  the  cortical  neurones  are  due  directly  to  the 
toxins  produced  by  the  micro-organism,  or  to  an  autotoxin 
developing  within  the  body  as  a  result  of  the  infectious 
disease. 

A.     Fever  Delirium 

The  clinical  picture  of  fever  delirium  presents  four  differ- 
ent grades   corresponding  to  the  intensity  of  the  toxic 

121 


122  FORMS  OF  MENTAL  DISEASES 

action  upon  the  cortical  neurones,  vaiying  from  moderate 
irritation  to  paralysis  and  finally  to  complete  destruction. 

Etiology.  —  The  form  of  febrile  disease  has  very  little  in- 
fluence on  the  type  of  delirium,  which  apparently  is  modified 
only  by  the  rapidity  of  the  development  of  the  fever,  its 
intensity,  and  duration.  There  seems  to  be  little  ground  for 
the  claim  that  the  mental  disturbance  occurring  during 
typhoid  is  more  or  less  characteristic.  Besides  the  toxin 
produced  in  the  febrile  disease,  the  rise  in  temperature, 
acceleration  of  metabolism,  and  disturbance  of  circulation 
should  be  regarded  as  causative  factors.  In  addition  there 
should  be  included  alcohol,  which  plays  such  an  important 
role  in  pneumonia,  giving  rise  to  symptoms  characteristic 
of  delirium  tremens,  such  as  illusions  and  hallucinations  of 
many  moving  objects  of  great  sensory  vividness,  the  occupa- 
tion delirium,  tremor,  and  a  mixed  emotional  state  showing 
both  elation  and  anxiety.  Furthermore,  the  individual's 
power  of  resistance  is  of  importance.  It  is  well  known 
that  children,  women,  and  nervous  men  show  a  tendency 
to  develop  delirium  with  any  severe  form  of  fever. 

The  pathological  anatomy  exhibits  mostly  a  disappear- 
ance of  the  cortical  cells  very  similar  to  that  which  can 
be  produced  experimentally  by  the  application  of  super- 
heated air  to  test  animals  as  well  as  many  other  deleterious 
agents. 

Symptomatology.  —  In  the  lightest  grade  of  fever  delir- 
ium there  is  irritability,  some  restlessness,  general  hyper- 
esthesia, insomnia  with  anxious  dreams,  a  feeling  of  numb- 
ness in  the  head,  and  a  desire  to  be  left  alone. 

In  the  next  grade  there  is  a  marked  clouding  of  con- 
sciousness; illusions  and  hallucinations  largely  dominate 
ideation,  producing  a  dreamy  confusion  of  thought.  The 
designs  on  the  carpet  and  ceiling  appear  as  moving  forms 


INFECTION  PSYCHOSES  123 

or  grinning  faces,  the  bedpost  assumes  the  form  of  an 
angel.  Frightful  outcries  or  beautiful  music  are  heard, 
patients  have  airy  floating  sensations,  and  are  led  about 
through  gorgeously  decorated  rooms.  These  dreamy  ex- 
periences are  interrupted  momentarily  by  a  return  to 
normal  consciousness.  The  emotional  attitude  becomes 
either  much  exalted  or  depressed,  and  motor  activity  in- 
creases greatly. 

In  the  third  grade  the  disturbance  of  consciousness 
becomes  very  pronounced.  The  patients  prattle  constantly, 
the  content  of  thought  showing  even  greater  dreamy  con- 
fusion. There  are  many  varied  emotional  outbreaks  and 
frequent  wild  impulsive  movements,  which  soon  become 
irregular  and  uncertain,  indicating  the  onset  of  paralysis. 
The  intense  restlessness  is  interrupted  by  short  periods  of 
sleep. 

In  the  fourth  grade  the  movements  become  absolutely 
purposeless.  At  this  time  carphologia  appears  with  sub- 
sultus  tendinum.  The  utterances  become  indistinct,  and 
consist  in  mumbling  over  incoherent  words  and  sentences. 
From  this  the  patient  may  enter  into  a  state  of  coma  vigil, 
when,  in  spite  of  open  eyes,  he  is  oblivious  to  all  his  sur- 
roundings and  unable  to  indicate  his  desires.  The  urine 
and  faeces  are  passed  involuntarily. 

The  intensity  of  the  motor  activity  varies  in  different 
individuals,  sometimes  reaching  an  extreme  degree  and  at 
other  being  confined  to  spasmodic  twitching  or  chorei- 
form movements  of  the  extremities,  or  merely  of  the 
face  and  tongue,  the  latter  producing  peculiar  enuncia- 
tion. 

Course. — The  duration  of  the  psychosis  in  three-fourths 
of  the  cases  does  not  extend  beyond  one  week,  and  usually 
the  delirium  subsides  with  the  temperature.    Some  of  the 


124  FORMS  OF  MENTAL  DISEASES 

delusional  ideas  held  during  the  disease  may  be  retained 
for  a  long  time. 

The  prognosis  is  naturally  poor  because  of  the  severity 
of  the  initial  disease.  If  the  delirium  advances  to  the 
third  or  fourth  grade,  at  least  one-third  of  the  cases  die. 
Where  there  is  hyperpyrexia  the  prognosis  is  extremely 
doubtful.  A  few  cases  emerge  from  the  fever  delirium 
into  an  exhaustion  psychosis,  or  may  end  in  dementia. 
Finally,  the  delirium  may  be  the  starting-point  of  other 
psychoses,  as  manic-depressive  insanity,  dementia  prsecox, 
or  dementia  paralytica. 

Besides  the  treatment  of  the  initial  disease,  the  ice  cap 
should  be  applied  to  relieve  cerebral  hyperemia.  Cold 
baths  or  cold  packs  with  friction  are  most  serviceable. 
In  case  of  cardiac  weakness  one  must  be  cautious  in  the 
use  of  the  bath,  and  if  necessary  administer  a  cardiac  stimu- 
lant. For  this  purpose  strong  coffee  is  valuable.  Anti- 
pyretics are  not  only  useless,  but  often  aid  in  producing  and 
intensifying  the  delirium.  One  of  the  most  important 
indications  is  constant  attendance,  both  to  prevent  harm  to 
others  and  injury  of  the  patient  by  escaping  out  of  doors 
or  jumping  out  of  windows.  If  the  excitement  becomes 
excessive,  one  should  resort  to  the  prolonged  warm  bath 
(see  p.  140).  This  measure  rarely  fails  to  bring  quiet.  In 
addition,  however,  a  clever,  reassuring  nurse  is  most  essential. 
The  method  of  applying  strait  jackets  and  restraint 
sheets  so  much  in  vogue  in  private  homes  and  general  hos- 
pitals should  be  decried.  If  impulsive  movements  are 
a  prominent  feature,  it  may  be  necessary  to  improvise 
padded  beds  with  high  sides,  or  to  resort  to  padded  rooms. 
The  use  of  hypnotics  and  narcotics  is  harmful  and  distinctly 
contraindicated.  Furthermore,  the  proper  use  of  hydro- 
therapy usually  renders  their  administration  unnecessary. 


INFECTION  PSYCHOSES  125 

B.     Infection  Deliria 

This  group  comprises  psychoses  which  appear  to  stand 
in  intimate  relationship  to  the  specific  toxaemia  of  certain 
infectious  diseases,  including  the  initial  deliria  of  typhoid 
and  smallpox  and  the  deliria  accompanying  malaria,  acute 
chorea,  and  influenza.  There  are  also  grouped  here  deliria 
that  develop  in  some  septic  states,  as  well  as  those  occurring 
in  toxic  states  of  a  less  specific  nature  and  presenting  the 
course  of  the  so-called  "  Acute  Dehrium." 

Initial  Deliria.  —  Of  the  infection  deliria,  the  initial  de- 
lirium of  typhoid  is  best  known.  Nissl  has  reported  on 
the  pathological  anatomy  in  one  case  in  which  there  was 
distention  of  the  vessels  of  the  cortex,  with  increase  of  white 
blood  corpuscles  and  pronounced  degenerative  changes  in 
the  nerve  cells.  The  cell  bodies  were  swollen,  the  chro- 
mophiles  were  dissolved,  and  the  processes  diffusely  stained 
for  some  distance.  Karyokinesis  was  observed  in  nuclei  of 
the  glia  cells.  These  changes,  which  are  similar  to  those 
produced  by  experimental  intoxication,  tend  to  prove 
that  we  have  to  do  with  a  psychosis  depending  upon  in- 
toxication. 

Aschaffenburg  *  distinguishes  two  forms  of  initial  delirium 
of  typhoid.  In  the  first  the  delirium  is  not  accompanied  by 
psychomotor  activity,  but  there  are  numerous  and  pronounced 
hallucinations  and  delusions,  mostly  of  a  threatening  and 
persecutory  nature ;  such  as,  cursing  voices,  visions  of  fright- 
ful and  threatening  forms,  and  ideas  of  poisoning  and  per- 
sonal injury.  The  emotional  attitude  is  usually  one  of 
intense  anxiety  and  sadness.  The  patients  are  often  pro- 
ductive and  relate  adventurous  experiences. 

The  other  form,  which,  indeed,  may  develop  directly  from 

1  Aschaffenburg,  Allgem.  Zeitschr.  f.  Psychiatrie  LII,  75. 


126  FORMS  OF  MENTAL  DISEASE 

the  first,  is  characterized  by  great  psychomotor  activity. 
The  delirium  usually  develops  rapidly  with  marked  hal- 
lucinations, incoherent  delusions,  delirious  confusion  of 
thought,  sometimes  flight  of  ideas,  also  an  intensely  anxious 
emotional  state,  together  with  senseless  impulsive  movements. 
During  the  initial  delirium  the  sleep  is  greatly  disturbed, 
and  there  is  little  appetite;  on  the  other  hand,  there  is 
usually  but  slight  rise  in  temperature,  and  the  pulse  is  not 
accelerated.  The  recognition  of  the  type  of  delirium  at  the 
onset  may  be  rendered  difficult  by  the  absence  of  the  char- 
acteristic typhoid  symptoms,  which  may  not  appear  until 
the  delirium  is  well  established.  Farrar  !  lays  stress  upon 
impaired  associative  activity,  fallacious  sense  deception,  with 
developing  delusions,  disorientation,  psychomotor  excite- 
ment, and  anxious  affective  states.  He  also  calls  attention 
to  certain  prodromal  symptoms,  which  may  exist  from  a 
few  hours  to  many  days,  as,  nervousness,  insomnia,  and 
nocturnal  restlessness,  and  believes  that  cases  with  a  sudden 
onset  are  more  uniformly  fatal  and  occur  particularly  in 
individuals  with  a  faulty  heredity. 

The  initial  delirium  of  smallpox  usually  develops  between 
the  third  and  fifth  days,  and  is  characterized  by  a  short 
violent  course.  The  symptoms  are  similar  to  those  observed 
in  the  initial  delirium  of  typhoid,  but  are  characterized  by 
an  even  greater  clouding  of  consciousness,  and  violent  con- 
duct with  a  tendency  to  commit  suicide,  in  which  respect 
one  is  reminded  of  the  epileptic  befogged  states.  Tremor 
and  convulsions  sometimes  develop.  The  symptoms  sub- 
side with  the  appearance  of  the  eruption,  but  occasionally 
extend  over  into  the  pustular  stage.  It  rarely  happens 
that  the  psychosis  passes  over  into  a  condition  of  dementia. 

'Farrar,  "On  Typhoid  Psychoses,"  Medical  Reports  of  the  Shepard 
and  Enoch  Pratt  Hospital,  1903.     Vol.  1,  No.  1,  p.  42. 


INFECTION  PSYCHOSES  127 

The  recognition  of  the  smallpox  delirium  depends  wholly 
upon  the  fever,  the  physical  symptoms,  and  circumstances 
pointing  to  this  infectious  disease. 

Another  type  of  mental  disturbance  characteristic  of 
smallpox  may  develop  between  the  eruption  and  pus  fever, 
in  which  the  patients  present  only  vivid  hallucinations  of 
sight  and  hearing,  while  in  other  respects  they  remain  well 
oriented,  clear  in  thought,  and  orderly  in  conduct.  The 
varied  visions  and  voices  simply  annoy  them  without  causing 
much  effect. 

The  course  in  these  initial  deliria  is  frequently  characterized 
by  partial  remissions  during  the  daytime,  in  which  the 
patients  continue  somewhat  clouded  and  do  not  wholly 
regain  insight  into  their  condition.  The  duration  of  the 
symptoms  rarely  extends  beyond  one  week,  and  usually  is 
much  shorter.  The  delirium  usually  clears  with  the  onset 
of  the  fever,  but  it  may  pass  over  into  the  characteristic 
fever  delirium. 

The  outcome  is  distinctly  unfavorable,  as  forty  to  fifty  per 
cent,  of  the  patients  die. 

The  infection  delirium  accompanying  malaria  is  distinctly 
intermittent,  either  accompanying  or  replacing  the  fever. 
It  occurs  most  frequently  in  the  tertian  and  quotidian  forms, 
and  rarely  in  the  quartan.  The  delirium  may  appear  only 
in  the  early  stages  of  the  disease,  during  this  time  replacing 
the  fever  for  a  few  days.  The  symptoms  develop  suddenly, 
and  consist  of  states  of  marked  anxious  excitement  with  pro- 
found clouding  of  consciousness  and  a  tendency  to  reckless 
violence.  All  of  these  symptoms  suddenly  disappear  after 
a  few  hours'  duration,  and  are  followed  by  profound  sleep, 
from  which  the  patient  awakes  with  little  or  no  memory  of 
the  attack.  The  delirium  always  responds  readily  to  the 
use  of  quinine. 


128  FORMS  OF  MENTAL  DISEASE 

The  delirium  that  accompanies  acute  chorea,  particularly 1 
when  associated  with  acute  polyarthritis  and  endocarditis, 
seems  to  belong  to  the  group  of  infection  psychoses.  It  is 
characterized  by  a  clouding  of  consciousness  with  a  peculiar 
dreamy  confusion  of  thought,  some  hallucinations  and  delu- 
sions and  emotional  irritability.  These  patients  apprehend 
single  impressions  fairly  well,  but  continue  disoriented  and 
are  inattentive  and  distractible.  Their  speech  is  character- 
ized by  monotonous  disjointed  sentences,  in  which  they 
occasionally  weave  incidental  observations.  While  they  may 
hear  voices  calling,  see  strange  visions,  and  express  perse- 
cutory or  fearful  delusions,  these  ideas  are  not  clear  and  are 
never  elaborated  further.  The  emotional  attitude  varies,  as 
at  times  they  are  anxious,  at  others  elated,  and  occasionally 
show  outbursts  of  passion. 

This  mental  picture  is  accompanied  by  a  condition  of 
almost  constant  choreic  excitation,  in  which  the  charac- 
teristic choreic  movements  continue  in  an  exaggerated  form 
both  day  and  night,  preventing  sleep  and  also  interfering 
greatly  with  nutrition.  The  duration  of  the  psychosis  is 
from  a  few  days  to  a  few  weeks,  and  not  infrequently  ter- 
minates fatally. 

Other  infectious  diseases  that  may  give  rise  to  a  delirious 
state  which  apparently  depends  upon  a  toxsemia,  are  in- 
fluenza, hydrophobia,2  and  certain  septic  states.  In  the  first 
there  is  apt  to  be  clouding  of  consciousness,  delirious  hal- 
lucinations, confusion  of  speech,  and  anxious  excitement. 
Sometimes  there  is  also  present  paralysis  of  speech  and 
deglutition,  as  well  as  polyneuritic  symptoms.    The  psy- 

1  Mobius,  Neural.  Beitrage,  II,  123, 1894;  Zinn,  Archiv  f.  Psy.  XXVIII, 
411,  1896;  Krafft-Ebing,  Wiener  Klin.  Rundschau,  1900,  30. 

2Hogyes,  Lyssa,  Nothnagel's  Handbuch  der  Pathologie  u.  Therapie, 
V,  5,  88,  1897. 


INFECTION  PSYCHOSES  129 

chosis  accompanying  hydrophobia  is  a  delirium  in  which 
hallucinations  predominate.  In  the  septic  states  the 
patients  may  develop  a  delirium  in  which  there  are  many 
hallucinations,  clouding  of  consciousness  with  disorientation, 
low  and  indistinct  mumbling,  and  attempts  to  grasp  at  in- 
visible objects.  At  times  the  condition  is  one  of  pronounced 
delirious  excitement. 

Finally,  there  is  a  group  of  cases  which  seem  more  properly 
classified  here  than  elsewhere.  It  includes  those  delirious 
states  that  sometimes  accompany  furunculosis  or  follow  a  slight 
physical  illness,  angina,  intestinal  catarrh,  obstinate  consti- 
pation, etc.,  or  may  occur  in  the  course  of  any  other  type  of 
psychosis,  which  suddenly  takes  a  turn  for  the  worse.  Some 
would  include  this  particular  type  of  delirium  with  certain 
other  states  of  marked  excitement,  and  denominate  them  all 
"  Acute  Delirium."  The  delirium  seems  to  arise  from  a 
recent  active  infectious  involvement  of  the  cortex,  as  shown 
in  the  pathological  anatomy,  by  an  acute  destruction  of 
the  nerve  cells,  sometimes  including  the  fibres,  in  ad- 
dition to  an  increase  of  the  glia,  and  vascular  changes 
with  diapedesis  of  leucocytes  and  occasionally  an  escape 
of  the  blood  corpuscles. 

The  patients  become  sleepless,  bewildered,  and  distracti- 
ble.  Numerous  hallucinations  of  sight  and  hearing  appear, 
and  incoherent  expansive  and  persecutory  delusions  are 
expressed.  They  prattle  away,  sometimes  pray,  and  finally 
speech  may  be  resolved  into  a  repetition  of  a  few  senseless 
words  and  syllables.  Emotionally,  they  may  be  anxious, 
elated,  or  irritable.  The  activity  is  greatly  increased  and 
accompanied  by  impulsiveness,  with  pounding,  dancing, 
yelling,  etc.  Food  is  usually  refused  and  the  patients  fail 
rapidly.  Temperature  develops;  and  there  appear  ecchy- 
moses  or  fat  embolism,  furunculosis,  gangrene  of  the  lung, 


130  FORMS  OF  MENTAL  DISEASE 

severe  catarrh  of  the  nose,  gangrene  of  the  mouth,  some- 
times parotitis  and  retention  of  urine  and  feces.  In  the 
vast  majority  of  cases  the  delirium  runs  a  fatal  course  in 
from  one  to  two  weeks. 

An  accurate  differentiation  of  this  form  of  psychosis  based 
alone  upon  the  symptoms  is  at  present  almost  impossible. 
The  delirious  states  which  sometimes  develop  in  paresis  and 
catatonia  are  recognized  only  by  the  previous  history  of 
symptoms  characteristic  of  these  diseases  antedating  the 
delirium.  Collapse  delirium,  which  may  arise  from  an  iden- 
tical toxic  state,  can  be  distinguished  only  by  the  relative 
observations  that  in  it  the  clouding  is  less  profound,  the 
activity  less  turbulent,  while  the  hallucinations  and  delu- 
sions are  more  vivid,  and  in  the  speech  both  distractibility 
and  flight  of  ideas  prevail. 

The  treatment  of  these  different  infection  deliria  depends 
in  some  measure  upon  the  treatment  of  the  underlying 
physical  disease.  In  view  of  the  toxic  origin  of  the  disease 
a  thorough  flushing  of  the  body  combined  with  infusion  of 
normal  salt  solution  is  excellent  practice.  One  may  employ 
the  prolonged  warm  bath  (see  p.  140)  for  relieving  the  motor 
excitement.  Sufficient  liquid  nourishment  is  always  indi- 
cated, which  may  have  to  be  administered  by  stomach  or 
nasal  tube.  The  bowels  must  be  kept  open,  for  which 
purpose  high  rectal  injection  of  normal  saline  solution  may 
be  used  twice  daily.  Furthermore,  the  mouth  should  be 
cleaned  by  frequent  swabbing.  In  case  medicinal  sedatives 
seem  advisable,  alcohol  and  paraldehyde  are  well  recom- 
mended, but  powerful  narcotics  and  sedatives  should  be 
sedulously  avoided.  Failing  heart  action  should  be  sup- 
ported by  the  use  of  caffein,  camphor,  or  ether. 


INFECTION  PSYCHOSES  131 

0.  Post   Infection   Psychoses 

These  psychoses  are  in  general  characterized  by  a  more  or 
less  pronounced  degree  of  intellectual  and  emotional  weak- 
ness, together  with,  in  most  instances,  pronounced  delusion 
formation  and  a  prevailing  sad  or  anxious  emotional  attitude. 
The  postfebrile  psychoses  described  here  by  no  means  in- 
clude all  of  the  psychoses  appearing  after  the  febrile  period 
in  infectious  diseases.  The  exhaustion  psychoses  as  well  as 
most  any  other  form  of  mental  disease  may  develop  during 
this  period.  The  first  symptoms  often,  but  not  always, 
appear  before  the  fever  wholly  subsides. 

The  mildest  form  of  postfebrile  infection  psychosis  is  rep- 
resented by  those  cases  in  which  after  the  subsidence  of  the 
fever  in  a  severe  attack  of  infectious  disease,  the  patients 
fail  to  show  their  former  physical  and  mental  energy.  They 
are  dull  and  sluggish,  and  are  very  susceptible  to  fatigue. 
They  cannot  collect  their  thoughts,  and  find  it  difficult  to 
read  and  write,  are  indifferent,  idly  lie  abed,  and  let  things 
go  as  they  will.  Orientation  is  undisturbed  and  there  usually 
are  no  hallucinations,  although  transient  hallucinations  may 
appear  after  closing  the  eyes,  when  for  a  few  moments  they 
hear  unintelligible  sounds,  see  faint  visions,  or  experience 
peculiar  bodily  sensations  which  are  interpreted  by  them  as 
grave  symptoms.  In  emotional  attitude  they  are  sad  and 
troubled,  sometimes  irritable,  and  occasionally  at  night  they 
suddenly  develop  a  state  of  great  anxiety.  They  may  at 
times  exhibit  a  distrust  of  their  surroundings,  transitory  fear 
of  poisoning,  hypochondriacal  ideas,  and  even  delusions  of 
persecution,  which  may  give  rise  to  aggressive  attacks  and 
attempts  at  suicide.  In  actions  they  are  inclined  to  be  re- 
served, sort  of  stupid,  and  reticent  about  their  delusions. 
Physically,  sleep  and  appetite  are  poor  and  body  weight 
much  reduced. 


132  FORMS   OF   MENTAL   DISEASE 

This  mild  form  follows  particularly  influenza  and  polyar- 
thritis, and  whooping  cough  in  children.  It  is  occasionally 
seen  in  tuberculous  and  choreic  cases.  After  a  duration  of 
a  few  weeks  to  a  few  months,  improvement  gradually  sets  in, 
provided  the  underlying  physical  disease  has  cleared  up. 
This  syndrome,  although  suggestive  of  chronic  nervous  ex- 
haustion, may  be  differentiated  from  it  by  the  fact  that 
the  symptoms  are  more  severe  and  stubborn,  and  do  not 
improve  under  rest  and  relaxation.  Furthermore,  there  is 
not  the  same  clear  insight  that  exists  in  chronic  nervous 
exhaustion. 

A  second  group  of  postfebrile  infection  psychoses  is  char- 
acterized by  more  pronounced  symptoms;  namely,  promi- 
nent hallucinations,  fantastic  delusions,  and  active  excite- 
ment with  anxiety.  When  the  symptoms  first  appear, 
which  is  always  during  the  febrile  period,  there  is  complete 
disorientation  with  marked  confusion  of  thought,  and  very 
many  hallucinations  which  may  involve  all  of  the  senses. 
After  the  temperature  subsides  and  the  symptoms  of  the 
initial  disease  disappear,  the  patients  gradually  become 
somewhat  oriented  and  more  composed,  but'  the  hallucina- 
tions and  delusions  persist.  They  still  hear  threatening 
voices,  see  grinning  faces  looking  in.  at  the  window,  and 
must  get  out  of  the  bed  and  at  them.  Some  one  pulls  the 
bedding,  the  food  is  not  genuine,  they  are  poisoned,  no  one 
is  willing  to  do  the  right  thing  for  them,  etc.  Emotionally, 
they  are  dejected,  anxious,  and  ill-humored.  Sometimes,  in 
outbursts  of  passion,  they  attempt  suicide  and  become 
violent.  They  are  apt  to  be  obstinate,  quarrelsome,  con- 
strained, and  resistive.  Physically,  there  is  faulty  nutrition 
and  insomnia.  As  the  appetite  and  sleep  improve,  the  hal- 
lucinations and  delusions  disappear.  The  patients  gain  in- 
sight into  their  condition,  begin  to  busy  themselves,  and 


POST  INFECTION   PSYCHOSES  133 

resume  their  accustomed  conduct,  but  for  some  time  they 
continue  to  show  an  unusual  susceptibility  to  fatigue,  and 
an  absence  of  the  wonted  mental  and  physical  energy,  to- 
gether with  weakness  of  memory.  A  few  cases  never  com- 
pletely recover.  A  fatal  termination  is  rare,  and  always  due 
to  exhaustion  or  some  complication.  The  duration  varies 
from  several  months  to  a  year.  This  form  follows  especially 
typhoid,  smallpox,  articular  rheumatism,  and  sometimes 
develops  during  tuberculosis. 

In  adults,  there  may  be  some  difficulty  in  differentiating 
this  condition  from  melancholia  of  involution  developing 
during  an  attack  of  some  infectious  disease.  It,  however, 
may  be  distinguished  by  the  greater  prominence  of  halluci- 
nations, the  predominance  of  delusions  of  persecution  over 
self-accusations,  and  the  great  irritability  in  contrast  to  the 
anxiety  of  the  melancholiac.  It  may  be  differentiated  from 
dementia  prcecox  by  the  greater  affect  and  disturbance  of 
apprehension  and  orientation  at  the  onset  of  the  disease, 
and  by  the  absence  of  negativism  and  stereotypy;  from  the 
depressive  phase  of  manic-depressive  insanity  by  the  absence 
of  psychomotor  retardation. 

The  third  and  severest  form  of  postfebrile  infection  psycho- 
sis is  characterized  by  a  severe  delirium  which  soon  passes 
over  into  a  condition  of  stupor.  In  spite  of  improvement  in 
the  physical  condition  the  patients  continue  dull,  and  inca- 
pable of  perceiving  and  elaborating  external  impressions,  and 
have  poor  memory  and  judgment.  Emotionally,  they  are  in- 
different, sometimes  peevish.  They  may  be  quiet  or  child- 
ishly restless.  They  lie  abed  unable  to  take  their  food  or 
care  for  themselves,  and  have  to  be  petted  and  handled  like 
small  children.  Physically,  they  fail  markedly  in  nutrition, 
and  occasionally  give  evidence  of  severe  cerebral  disorder, 
as  hemiplegia,  disturbance  of  speech,  and  epileptiform  attacks. 


134  FORMS  OF  MENTAL  DISEASE 

The  prognosis  is  dubious,  as  after  an  extended  course  of  many 
months  only  one-half  of  the  cases  recover.  The  other  cases 
improve  gradually  but  present  as  residuals,  weakness  of 
will-power,  poor  judgment,  forgetfulness,  poverty  of  thought, 
and  apathy.  This  form  follows  chiefly  typhoid  fever,  and 
sometimes  malaria.  It  may  be  distinguished  from  the  stupor 
of  the  catatonic  state  by  the  absence  of  negativism,  and  from 
the  stupor  of  the  manic-depressive  by  the  absence  of  retarda- 
tion and  the  presence  of  faulty  memory. 

The  treatment  of  all  these  three  types  of  postfebrile  infec- 
tion psychosis  is  mostly  symptomatic,  with  veiy  careful 
nursing,  rest  in  bed,  nutritious  diet,  and  cautious  watching. 

Still  another  group  of  postfebrile  infection  psychoses  is 
the  "  Cerebropathia  psychica  toxamica,"  which  was  first 
described  by  Korssakow  *  (Korssakow's  "  Psychosis, " 
"Polyneuritis  Psychosis,"  "  Neurocerebrite  Toxique"). 
It  is  characterized  by  a  pronounced  disturbance  of  that  ele- 
ment of  memory  which  we  call  impressibility,  also  by  disorien- 
tation and  the  physical  signs  of  polyneuritis,  associated  some- 
times with  a  delirious  excitement  or  stupidity.  The  symp- 
toms of  this  form  of  polyneuritic  psychosis  are  very  similar  to 
the  alcoholic  polyneuritic  psychosis  (see  p.  184),  and  can  be 
distinguished  only  by  their  more  prolonged  course  and  the 
history  of  the  underlying  physical  state.  The  duration  of  the 
psychosis  extends  over  many  months,  in  case  death  does  not 
occur,  and  the  outcome  is  rather  more  favorable  than  in  the 
alcoholic  cases.  The  treatment  is  practically  the  same  as 
that  outlined  in  the  other  forms,  with  the  exception  that 
some  attention  must  be  paid  to  the  muscular  atrophies, 

1  Korssakow,  Gazette  russe  hebdomadaire  clinique,  1889,  No.  57; 
Meyer  in  Raecke,  Archiv  f.  Psych.,  1903,  Bd.  37,  H.  I;  Turner,  Jour,  of 
Ment.  Sci.,  October,  1903;  Miller,  Am.  Jour.  f.  Ins.,  LX,  No.  4,  1904; 
Frie    ftnder,  Monatschr.  f .  Psych.,  VI,  4491 ;  Raimann,  idem.,  XII,  329. 


POST  INFECTION  PSYCHOSES  135 

which  demand  the  use  of  electricity  and  massage  after  the 
subsidence  of  the  acute  neuritic  symptoms. 

There  is  still  another  form  of  postfebrile  infection  psy- 
chosis, different  from  any  of  the  preceding  forms,  which  is 
characterized  by  the  sudden  appearance  of  active  excite- 
ment with  clouding  of  consciousness,  flight  of  ideas,  and 
fantastic  expansive  delusions,  simulating  the  symptoms  of 
the  expansive  paretic.  Following  a  few  indefinite  prodromal 
symptoms  there  appears  first,  usually  during  the  febrile 
period,  considerable  restlessness,  then  disorientation,  dis- 
tractibility,  and  hallucinations  of  sight  and  hearing,  and 
finally  the  most  elaborate  grandiose  delusions.  The  patients 
also  fabricate  extensively.  Emotionally,  they  are  some- 
times irritable,  sometimes  elated,  but  always  changing 
rapidly  from  one  state  to  another.  There  is  absolutely  no 
insight.  In  addition,  the  patients  are  productive  and  show 
a  flight  of  ideas  with  a  tendency  to  rhyming.  The  restless- 
ness is  so  great  that  they  cannot  remain  in  bed.  Little  food 
is  taken,  sleep  is  scanty,  and  nutrition  suffers  greatly.  This 
form  follows  typhoid.  In  part  of  the  cases  the  course  is  rapid 
and  the  outcome  favorable.  After  some  months  the  excite- 
ment and  the  delusions  gradually  disappear.  The  patients, 
however,  continue  to  be  irritable,  susceptible  to  fatigue,  and 
upon  slight  mental  application  easily  develop  again  flight  of 
ideas  and  delusional  fabrications,  and  may  show  a  char- 
acteristic silly  elation  even  when  convalescence  is  well 
established.  In  a  considerable  number  of  cases  dementia 
ensues.  This  form  may  be  distinguished  from  paresis  by  the 
absence  of  physical  signs.  The  treatment  consists  mostly  of 
continued  rest  in  bed,  prolonged  warm  baths  to  alleviate 
the  excitement,  a  nutritious  diet,  and  very  careful  nursing. 


II.  EXHAUSTION  PSYCHOSES 

The  exhaustion  psychoses,  collapse  delirium,  amentia,  and 
chronic  nervous  exhaustion,  include  those  forms  of  mental 
disease  that  seem  to  arise  from  excessive  exhaustion  or  in- 
sufficient restoration  of  the  nervous  elements  in  the  cerebral 
cortex.  The  term  "  exhaustion  "  is  most  applicable  to  those 
psychoses  that  immediately  follow  a  severe  and  radical 
change  of  the  physical  organism,  such  as  that  produced  by 
acute  diseases,  excessive  loss  of  blood,  and  childbirth.  But 
even  here  one  cannot  always  exclude  the  possibility  of  a 
toxaemia  arising  from  an  infectious  organism  or  from  the 
destruction  of  tissue.  A  more  accurate  knowledge  may 
result  in  these  forms  being  grouped  elsewhere  and  as- 
cribed to  other  etiological  factors.  This  occurred  in 
the  case  of  "  acute  dementia,"  which  is  now  classed 
in  the  group  of  post  infection  psychoses,  except  when 
it  represents  a  phase  in  catatonia  or  manic-depressive 
insanity. 

Collapse  delirium  and  amentia,  though  they  run  a  slightly 
different  course,  have  many  symptoms  in  common;  namely, 
a  profound  disturbance  of  apprehension  and  of  the  cohe- 
rence of  thought,  as  well  as  hallucinations,  flight  of  ideas,  and 
psychomotor  excitement.  Exhaustion  arising  from  more 
prolonged  mental  and  emotional  stress,  or  extended 
physical  illness,  produces  the  less  acute  but  more  chronic 
psychosis,  chronic  nervous  exhaustion  (acquired  neuras- 
thenia). 

136 


EXHAUSTION   PSYCHOSES  137 

A.    Collapse  Delirium 

This  psychosis  is  characterized  by  an  acute  onset  with 
profound  clouding  of  consciousness,  great  incoherence  of 
thought,  dreamy  hallucinations,  a  changeable  emotional  atti- 
tude, and  great  psychomotor  activity,  a  rapid  course,  and  a 
fairly  favorable  prognosis. 

Etiology.  —  Collapse  delirium  is  a  rare  form  of  insanity. 
Among  the  exhausting  conditions  giving  rise  to  it,  child- 
birth is  the  most  prominent;  others  are  loss  of  blood,  exces- 
sive mental  strain,  emotional  shock,  and  deprivation  with 
anxiety.  The  acute  diseases  which  may  lead  to  this  condi- 
tion are  pneumonia  and  erysipelas.  Oftentimes  a  fright 
occurring  while  the  patient  is  in  a  weak  condition  acts  as 
the  exciting  cause. 

Pathological  Anatomy.  —  Unfortunately  but  few  cases 
have  been  examined  pathologically.  Alzheimer,1  in  a  case 
which  seems  to  belong  to  this  group,  found  throughout  the 
cerebral  cortex  a  fine  granular  disintegration  of  the  chro- 
matic substance,  and  without  much  involvement  of  the 
nucleus  or  increase  of  glia. 

Symptomatology.  —  Following  a  few  days  of  insomnia  and 
restlessness,  the  patients  rapidly  become  disoriented  and 
everything  about  them  seems  changed  and  unnatural. 
Numerous  dreamy  illusions  and  hallucinations  appear;  the 
designs  on  the  carpet  assume  the  form  of  threatening  figures, 
gas  light  appears  like  the  sun,  neighbors  pass  to  and  fro, 
beautiful  music  is  heard,  and  patients  pass  through  all  sorts 
of  dreamy  experiences. 

They  become  very  talkative,  the  content  of  speech  show- 
ing great  incoherence  with  a  flight  of  ideas,  many  allitera- 

1  Wanderversammlung  d.  suedwest  Neurolog.  u.  Irrenraetze  an 
Baden-Baden,  1897. 


138  FORMS  OF  MENTAL  DISEASE 

tions,  rhymes,  and  repetitions,  which  may  be  sung  as  well 
as  spoken.  Numerous  delusions  are  expressed  which  are 
incoherent,  changeable,  and  both  exalted  and  depressive. 
In  emotional  attitude  patients  are  much  exalted  and  some- 
times erotic ;  depression  with  anxiety,  however,  may  pre- 
dominate the  emotional  tone.  Occasionally  there  is  irrita- 
bility with  exhibitions  of  passion. 

The  motor  excitement  is  very  pronounced;  patients  re- 
move their  clothing,  race  about  the  room,  overturn  furni- 
ture, and  pound  the  door.  They  are  both  destructive  and 
untidy,  and  often  exhibit  the  most  reckless  and  impulsive 
movements.  They  prattle  away  incessantly,  sometimes  in 
a  whisper,  now  at  the  top  of  their  voice,  and  again  gesticu- 
lating and  clapping  their  hands.  The  attention  cannot  be 
attracted  and  questions  are  rarely  answered.  They  will  not 
obey  requests,  but  almost  always  exhibit  a  purposeless 
resistance  to  everything,  even  to  bathing  and  dressing. 

Physically.  —  There  is  great  insomnia.  If  the  patients 
sleep  at  all,  it  is  only  for  short  intervals.  Likewise  they  take 
but  little  nourishment,  and  in  many  cases  require  mechani- 
cal feeding.  The  condition  of  nutrition  is  wretched,  and 
there  is  a  marked  loss  of  flesh  and  physical  weakness.  The 
skin  is  pale  and  clammy,  the  temperature  usually  subnormal, 
and  the  pulse  weak  and  irregular.  The  reflexes  are  usually 
exaggerated.  Tremor  is  sometimes  present  and  there  is  a 
tendency  to  acute  decubitus. 

Course.  — The  duration  of  the  disease  is  brief,  sometimes 
of  only  a  few  hours  or  days,  and  rarely  lasting  over  one  to 
two  weeks.  The  return  to  consciousness  is  usually  sudden, 
often  following  a  sound  sleep.  When  the  patients  awaken, 
the  hallucinations  and  illusions  have  disappeared;  they  are 
conscious  of  their  surroundings  and  ask  for  nourishment. 
They  may  continue  talkative,  perhaps  showing  a  flight  of 


EXHAUSTION  PSYCHOSES  139 

ideas,  some  exaltation,  grumbling,  and  fretful  manners  for 
several  hours  and  even  days.  Brief  relapses  sometimes  occur, 
As  soon  as  nourishment  is  freely  taken,  the  weight  increases 
rapidly. 

Diagnosis. — The  differentiation  from  infection  delirium 
has  already  been  considered  (see  p.  130).  The  epileptic  be- 
fogged states  are  distinguished  by  the  greater  clouding  of 
consciousness,  a  more  uniform  emotional  tone  which  is 
mostly  anxious  or  ecstatic,  and  the  fact  that  the  activity 
does  not  conform  to  the  thought  or  the  emotional  expres- 
sions. The  catatonic  excitement  is  recognized  by  the  clearer 
orientation,  and  the  characteristic  catatonic  movements. 
The  delirious  excitement  of  dementia  paralytica  can  be  dif- 
ferentiated only  by  the  history  of  preceding  mental  deteriora- 
tion and  the  presence  of  characteristic  physical  signs.  The 
delirious  mania  of  manic-depressive  insanity,  in  the  absence 
of  a  history  of  previous  attacks,  can  be  recognized  only  by 
a  greater  disturbance  of  apprehension  and  the  very  vivid 
hallucinosis.  Amentia  is  differentiated  by  the  longer  course 
and  distractibility  of  the  attention. 

Prognosis.  —  Recovery  from  the  mental  disorder  is  usual 
if  the  patients  do  not  die  from  collapse. 

Treatment.  —  The  important  indications  are  first  to  main- 
tain nutrition  and  next  to  alleviate  the  excitement.  The 
patients  must,  therefore,  receive  a  sufficient  quantity  of 
liquid  nourishment,  in  the  accomplishment  of  which  it  is 
often  necessary  to  resort  to  forced  feeding  by  stomach  or 
nasal  tube.  A  little  alcohol  (one  to  two  ounces)  added  to 
the  milk  and  egg  is  extremely  valuable.  Broths  and  pep- 
tonized meats  may  be  given  in  small  quantities.  Where 
mechanical  feeding  is  contraindicated,  because  of  vomiting  or 
abrasion  and  hemorrhage  of  the  mucous  membrane,  nutrient 
enemata  can  be  substituted.    Failing  in  this  one  can  always 


140  FORMS  OF  MENTAL  DISEASE 

resort  to  the  hypodermoclysis  of  normal  saline  solution,  one 
to  two  pints,  with  the  expectation  of  securing  excellent  re- 
sults, especially  if  there  is  impending  collapse.  The  infu- 
sion should  be  given  under  low  pressure  in  the  back,  rump, 
or  breast. 

In  the  alleviation  of  the  excitement,  by  far  the  most  effi- 
cient remedy  is  the  prolonged  warm  bath,  into  which  the 
patient  should  be  placed  at  once  and  kept  there  until  the 
excitement  subsides.  The  bath  should  be  maintained  at 
ninety-five  to  ninety-eight  degrees  F.  all  the  time.  The 
patients  may  remain  in  the  bath  without  fear  of  harm  for 
hours  and  even  days  at  a  time,  but  usually  they  become 
quiet  in  less  than  an  hour,  when  they  should  be  returned 
to  bed.  As  soon  as  the  excitement  reappears,  they  should 
again  be  placed  in  the  bath.  If  the  patients  exhibit  fear 
in  entering  the  bath  and  require  holding,  the  bath  can  do 
but  little  good.  In  such  cases,  one  may  give  a  hypodermic 
injection  of  hyoscine  hydrobromate,  2o~o  *0  ^o"  grain,  or 
trional,  15  grains,  shortly  before  the  bath  for  the  first  few 
times.  As  soon  as  the  patients  become  accustomed  to  the 
bath  they  usually  like  it,  and  some  even  fall  asleep  in  it. 
If  the  bath  is  not  available  and  one  must  resort  to  hyp- 
notic and  sedative  drugs,  hyoscine  hydrobromate  giro  to  ^0 
grain  and  paraldehyde  forty-five  minims  to  one  drachm 
may  be  relied  upon  for  the  best  results.  One  should  not 
be  persuaded  to  overload  the  system  with  sedatives  in  an 
effort  wholly  to  subdue  the  excitement  in  the  hope  of  secur- 
ing quiet  for  others.  Excitement,  of  itself,  is  by  no  means 
the  most  serious  symptom.  It  is  sufficient  if  you  succeed  in 
procuring  even  a  few  hours'  sleep  and  prevent  the  patients 
from  wholly  exhausting  themselves.  Prolonged  warm  baths 
properly  applied  usually  render  unnecessary  the  use  of 
sedatives.     If  the  patients  collapse,  hot  coffee  by  mouth  or 


EXHAUSTION  PSYCHOSES  141 

rectum,  strychnia,  dignitalis,  or  hypodermic  injections  of 
camphorated  oil  are  indicated. 

It  is  best  that  the  patients  be  isolated  in  a  quiet  place,  with 
sufficient  attendance  to  control  them  at  all  times.  Constant 
attendance  must  be  enforced  in  order  to  prevent  injuries, 
and  this  must  be  observed  until  convalescence  is  well  es- 
tablished. Mechanical  restraint  should  not  be  employed;  a 
padded  bed  or  room  is  preferable.  During  convalescence 
the  same  indications  obtain  here  as  in  convalescence  from 
any  acute  disease :  careful  feeding,  graduated  exercise,  and 
freedom  from  all  forms  of  excitement.  Finally,  one  must 
be  assured  of  complete  recovery  before  the  patients  are  per- 
mitted to  resume  their  usual  occupation  or  responsibilities. 
A  good  index  of  this  is  found  in  the  weight,  which  should 
always  return  to  normal. 

B.   Acute  Confusional  Insanity  (Amentia) 

This  form  of  exhaustion  psychosis  is  characterized  by  the 
rapid  appearance  of  numerous  illusions  and  hallucinations, 
clouding  of  consciousness,  and  motor  excitement,  with  a 
duration  of  two  to  three  months. 

Etiology.  —  The  conditions  of  exhaustion  giving  rise  to 
amentia  are  chiefly  childbirth,  also  acute  illnesses,  excessive 
loss  of  blood,  excessive  mental  strain,  and  night  watching. 
An  emotional  shock  may  be  the  final  exciting  factor.  Women 
are  more  frequently  affected  than  men.  Cases  of  amentia 
represent  about  one-half  to  one  per  cent,  of  the  admissions  to 
hospitals. 

Symptomatology.  —  At  first  the  patients  are  anxious,  rest- 
less, and  forgetful,  sometimes  complaining  of  numbness  and 
confusion  in  the  head,  and  inability  to  gather  their  thoughts 
or  concentrate  their  attention.  In  the  course  of  a  few  days 
disorientation  appears;  the  surroundings  seem  changed,  and 


142  FORMS  OF  MENTAL  DISEASE 

they  do  not  recognize  relatives.  Hallucinations  of  the  dif- 
ferent senses  appear.  They  see  strange  faces  and  hear 
strange  voices,  birds  are  flying  about,  lions  are  roaring, 
poisonous  powder  is  thrown  at  them,  and  they  are  threatened 
and  cursed  by  strangers.  The  numerous  hallucinations 
form  the  basis  for  many  depressive  delusions,  which  are 
dreamy,  incoherent,  contradictory,  and  often  repeated. 
Their  children  are  dead,  the  home  is  lost,  they  are  to  be 
hung,  are  under  the  influence  of  some  magnetic  power  which 
draws  them  about,  and  in  the  end  will  consume  them.  In 
a  few  cases  the  delusions  are  expansive;  they  then  believe 
themselves  exalted  to  some  high  position,  possessed  of  great 
wealth,  or  they  have  journeyed  around  the  world.  They 
will  convene  Congress,  and  send  an  army  to  Cuba.  They 
sometimes  fabricate  extensively. 

The  attention  is  attracted  by  the  surroundings  and  the 
patients  endeavor  to  grasp  what  transpires.  It  is  usually 
possible,  also,  to  direct  the  train  of  thought  by  objects  held 
before  them,  by  movements  and  gestures;  but  they  under- 
stand readily  only  the  simplest  occurrences.  Some  patients 
claim  that  everything  is  changed,  things  are  not  genuine, 
the  chairs  and  windows  are  not  the  same  to-day  as  yester- 
day, the  thermometer  is  not  correct,  the  clock  is  not  right, 
and  the  papers  are  incorrectly  dated.  Often  the  patients 
appreciate  this  inability  to  understand  things,  and  complain 
that  they  cannot  "think  right  "  or  that  some  one  "has  made 
them  crazy." 

There  is  marked  disturbance  of  the  train  of  thought.  The 
patients  are  unable  to  complete  one  idea  before  others  in- 
terrupt, producing  a  flight  of  ideas.  Words  and  sounds 
caught  up  from  the  surroundings  find  a  place  in  their  ex- 
pression, though  not  necessarily  influencing  or  directing  the 
train  of  thought.    The  speech  is  sometimes  made  up  of 


EXHAUSTION  PSYCHOSES  143 

single,  incoherent,  and  disjointed  words  and  phrases.  Occa- 
sionally sound  associations  and  rhymes  are  heard.  In  spite 
of  distractibility  and  flight  of  ideas,  one  occasionally  finds 
the  patients  holding  to  single  indefinite  ideas,  usually  of 
persecution.  The  consciousness  is  much  clouded.  The  per- 
sistence of  clouded  consciousness,  with  difficulty  in  arrang- 
ing the  impressions  and  ideas,  is  a  characteristic  and  striking 
feature  during  the  intervals  when  the  patients  are  quiet  and 
present  a  normal  emotional  attitude. 

The  emotional  attitude  varies  considerably,  sometimes  with 
prevailing  happiness,  but  more  often  with  depression.  Alter- 
nations of  the  attitude  are  characteristic;  for  short  periods 
the  patients  may  be  elated,  and  hilarious,  with  perhaps 
some  sexual  excitement,  when  they  suddenly  become  excited 
and  irritable,  or  they  may  even  be  dull  and  stupid. 

In  the  psychomotor  field  there  is  a  marked  pressure  of 
activity.  They  move  about  restlessly,  crawl  in  and  out  of 
bed,  destroy  clothing,  pound  and  beat,  but  the  movements 
are  not  very  quick,  are  performed  without  display  of  much 
energy,  and  are  planless.  The  motor  excitement  is  dis- 
tinctly intermittent,  there  being  intervals  of  complete  quiet. 

Physically.  —  The  sleep  is  much  disturbed,  the  appetite  is 
poor,  and  sometimes  there  is  complete  refusal  of  food.  The 
body  weight  falls,  but  the  condition  of  nutrition  is  better 
than  in  collapse  delirium.  The  deep  reflexes  are  increased, 
the  pulse  slow,  and  the  temperature  subnormal. 

Course.  —  The  height  of  the  disease  is  usually  reached 
within  two  weeks,  during  which  time  there  may  have  been 
remissions  of  a  few  hours  or  even  a  day  with  clear  conscious- 
ness, insight,  and  disappearance  of  hallucinations.  From 
this  time  the  symptoms  present  characteristic  fluctuations. 
The  more  active  symptoms  may  disappear,  and  the  patients 
become  more  coherent  in  speech,  when  again  they  develop 


144  FORMS  OF  MENTAL  DISEASE 

excitement.  Genuine  improvement  develops  gradually. 
Even  after  they  have  become  clear,  long  conversations  or 
letter-writing  tend  to  create  confusion.  In  the  lighter  cases, 
which  are  the  more  numerous,  even  after  the  patients  have 
become  quite  clear,  the  emotional  attitude  may  show  a 
slightly  elated  or  depressed  condition,  as  seen  in  hyper- 
activity and  garrulity,  or  distrust,  anxiety,  and  irritability. 
The  entire  course  is  from  three  to  four  months.  In  the 
severer  cases,  lasting  some  months,  even  when  the  patients 
have  become  clear,  a  few  hallucinations  may  persist  for  a 
short  time,  and  occasionally  indefinite  and  transitory  ex- 
pansive or  depressive  delusions  are  expressed.  The  patients 
may  appear  unnatural  and  irritable  and  show  outbursts  of 
passion.  Even  after  all  the  symptoms  of  the  disease  have 
disappeared,  the  patients  are  very  apt  to  show  increased 
susceptibility  to  fatigue,  while  for  many  months  emotional 
shocks  or  injuries  are  prone  to  create  relapses.  The  weight 
rises  rapidly  during  convalescence. 

Diagnosis.  —  The  manic  form  of  manic-depressive  insan- 
ity is  distinguished  from  amentia  by  the  fact  that  there 
is  less  disturbance  of  apprehension  than  of  the  psychomotor 
sphere;  in  the  manic  state,  in  spite  of  great  motor  excite- 
ment, the  patients  usually  give  evidence  of  at  least  a  partial 
comprehension  of  the  environment.  Again  in  amentia  the 
movements  are  slower,  more  planless,  and  less  precipitous, 
and,  in  quiet  intervals,  when  there  is  no  activity,  the  patients 
are  still  hazy  and  confused.  The  condition  of  catatonic 
excitement  is  distinguished  by  the  fact  that  the  catatonic 
patients  in  the  midst  of  the  greatest  excitement  are  usually 
able  to  comprehend  their  surroundings,  to  reckon  time 
correctly,  to  recognize  persons,  and  to  record  some  passing 
events.  The  amentia  patients  even  during  quiet  are  some- 
what disoriented  and  fail  to  recall  passing  events.     Further- 


EXHAUSTION  PSYCHOSES  145 

more,  the  characteristic  catatonic  features  are  absent.  To 
be  sure,  catalepsy  and  automatism  may  be  present,  but 
genuine  negativism,  verbigeration,  stereotypy,  mutism,  and 
mannerism  are  absent. 

Prognosis.  —  Death  rarely  occurs  except  as  the  result  of 
suicide,  of  collapse  during  the  intense  excitement  at  the 
onset,  or  precarious  physical  conditions;  as,  heart  failure, 
sepsis,  and  phthisis.  The  patients  almost  always  fully 
recover  their  mental  health. 

Treatment.  —  The  indications  for  treatment  are  identical 
with  those  in  collapse  delirium;  namely,  maintenance  of 
nutrition  and  the  alleviation  of  the  excitement  (see  p.  140). 
On  account  of  the  great  tendency  to  relapse,  one  should  be 
extremely  careful  about  allowing  the  patients  to  enter  an 
environment  in  which  they  might  be  subjected  to  an  emo- 
tional shock.  For  this  same  reason,  one  cannot  resist  too 
long  the  entreaties  of  the  patients  and  their  relatives  that 
they  be  allowed  to  enter  their  accustomed  life,  before  they 
have  regained  their  normal  weight,  the  menses  have  re- 
appeared, and  the  emotional  attitude  has  become  wholly 
stable. 


0.   ACQUIRED  NEURASTHENIA 

Chronic  Nervous  Exhaustion 

Acquired  neurasthenia  is  characterized  by  a  diminished 
'power  of  attention,  distractibility,  defective  mental  application, 
difficulty  of  thinking,  an  increased  susceptibility  to  fatigue, 
increased  emotional  irritability,  and  a  great  variety  of  physical 
symptoms,  mostly  subjective,  including  hypochondriasis. 

Acquired  neurasthenia  must  be  clearly  distinguished  from 
the  psychopathic  states  or  congenital  neurasthenia  (see 
p.  155) .  No  doubt  there  are  many  transitional  states  between 
the  two  diseases,  and  especially  where  both  defective  hered- 
ity and  exhaustion  are  prominent  factors.  The  difference 
in  the  symptoms,  their  course  and  outcome,  in  individuals 
free  from  hereditary  taints,  it  seems,  is  sufficiently  distinctive 
to  justify  the  restricted  use  of  the  term  acquired  neurasthenia. 

Etiology.  —  The  real  nature  of  the  disease  has  been  most 
logically  pointed  out  by  Mobius,  who  claims  that  there  is  a 
kind  of  chronic  intoxication  resulting  from  the  effects  of 
exhaustion  upon  nervous  tissue,  corresponding  in  a  measure 
to  the  intoxication  resulting  from  the  prolonged  excessive 
use  of  alcohol.  This  view,  certainly,  is  helpful  because  it 
offers  a  clearer  conception  of  the  disease  and  aids  in 
distinguishing  between  those  cases  which  simply  involve  an 
accumulation  of  the  effects  of  fatigue  and  those  in  which  the 
morbid  hereditary  and  inherently  impaired  powers  of  re- 
sistance  play  the  essential  role  (congenital  neurasthenia). 

The  rapid,  irregular,  and  extravagant  manner  of  living, 
with  little  relaxation  and  lack  of  sufficient  and  wholesome 

146 


ACQUIRED  NEURASTHENIA  147 

sleep  in  individuals  actively  engaged  in  business  or  taxed 
with  the  responsibilities  of  the  household,  is  distinctively- 
characteristic  of  the  American  people  in  the  temperate 
regions,  and  accounts  for  the  great  prevalence  of  this  disease 
in  our  nation.  Besides  excessive  mental  application,  the 
worry  attendant  upon  responsibility  is  an  important  factor. 
On  the  other  hand,  prolonged  and  excessive  physical  exer- 
tion is  at  times  undoubtedly  an  important  factor  in  produc- 
ing neurasthenia,  particularly  excessive  bodily  exercise,  as  is 
occasionally  seen  in  sports,  such  as  golf,  rowing,  basket 
ball,  etc.  But  of  especial  importance  are  our  faulty  meth- 
ods of  living,  with  insufficient  relaxation  and  improper 
nourishment.  Moreover,  considerable  depends  upon  the 
individual  powers  of  resistance.  This  is  particularly  appli- 
cable to  that  considerable  group  of  individuals,  who  always 
feel  unequal  to  the  demands  made  upon  them  and  find 
themselves  quickly  and  completely  exhausted  upon  any 
strenuous  effort. 

Of  the  men,  naturally  those  who  are  more  talented, 
better  educated,  and  more  active,  are  the  individuals  who 
most  often  suffer  from  this  disease.  Indeed,  it  is  a  fact 
worthy  of  note  that  great  capacity  for  work  is  frequently 
accompanied  by  greater  susceptibility  to  fatigue.  Women, 
because  of  their  weaker  powers  of  resistance  and  their  greater 
emotional  irritability,  are  more  susceptible  than  men,  par- 
ticularly the  overburdened  mothers,  teachers,  and  nurses. 
The  disease  may  appear  at  all  ages,  but  is  most  often  met 
between  the  ages  of  twenty-five  and  forty-five,  the  period  of 
life  during  which  the  greatest  mental  strain  occurs.  At  an 
earlier  age  it  is  seen  in  ambitious  students  who  apply  them- 
selves too  closely  to  studies  without  relaxation.  Occasionally 
symptoms,  which  differ  in  no  respect  from  those  described 
here,  develop  after  emotional  shocks  and  acute  illnesses, 


148  FORMS  OF  MENTAL  DISEASE 

especially  influenza,  childbirth,  loss  of  blood,  and  operations. 
The  "  nervous  weakness"  which  appears  during  convales- 
cence from  severe  illness  is  only  in  part  due  to  simple  ex- 
haustion. It  is  doubtful  if  the  disease  ever  develops  after  a 
fright. 

Symptomatology.  —  Prolonged  work  produces  fatigue 
and  with  it  difficulty  of  further  application.  Up  to  a  certain 
degree,  this  fatigue,  which  may  be  considered  as  a  safeguard 
against  overwork,  may  be  overcome  by  an  increased  exertion 
of  will  power,  which  in  long  and  fatiguing  work  gives  rise  to 
a  feeling  of  "  increased  effort."  Associated  with  this  there 
soon  develops  a  characteristic  feeling  of  disinclination  and 
then  a  fagging  of  the  will,  and  when  this  appears  the  danger 
of  overexertion  is  relieved.  While  the  increased  exertion  of 
the  will  can  for  a  time  balance  the  effects  of  fatigue  through 
an  increased  expenditure  of  power,  the  effects  of  fatigue 
ultimately  gain  the  upper  hand  and  force  one  to  cease  work. 

The  first  indications  of  exhaustion  are  when,  under  cer- 
tain conditions,  the  increased  exertion  of  will  continues  for 
some  time  in  spite  of  the  uncomfortable  feeling  of  fatigue. 
This  is  what  happens  when  work  is  performed  under  intense 
emotional  excitement.  The  signs  of  fatigue,  which  call  for 
relaxation,  either  do  not  appear  or  are  overwhelmed,  and 
work  is  prolonged  beyond  a  permissible  degree.  This  in 
time  leads,  on  the  one  hand,  to  an  exhaustion  of  the  available 
supply  of  strength,  which  recuperates  only  very  slowly,  and 
is  manifested  by  a  sort  of  prolonged  weariness,  which  persists 
after  relaxation  and  is  still  present  to  some  extent  when 
work  is  again  undertaken.  It  also  involves  an  increased 
susceptibility  to  fatigue  and  a  more  rapid  diminution  of  the 
capacity  for  work.  On  the  other  hand,  under  such  circum- 
stances, the  increased  exertion  of  the  will  also  persists  and 
brings  with  it  an  increased  emotional  irritability. 


ACQUIRED  NEURASTHENIA  149 

Unfortunately,  there  are  as  yet  no  experiments  on  the 
effect  of  prolonged  overexertion  on  the  mind.  But  we  know 
from  long  experience,  that,  first  of  all,  the  ability  to  con- 
tinuously exert  the  attention  fails.  The  patient  is  easily 
distracted  by  little  things  and  is  inattentive.  He  is  no 
longer  able  to  think  clearly  and  sharply,  and  requires  much 
more  time  for  his  accustomed  work.  He  is  also  apt  to  be 
forgetful  of  names  and  figures,  so  that  the  same  work  has  to 
be  done  over  several  times  before  he  is  sure  of  his  results. 

His  susceptibility  to  fatigue  is  greatly  increased,  and  his 
work  is  carried  out  only  with  constantly  increasing  difficulty, 
requiring  greater  exertion  and  more  frequent  rests.  As  the 
result  of  this  difficulty  of  work,  the  patient  also  loses  the 
wonted  pleasure  in  his  occupation.  He  finds  that  he  is 
compelled  to  force  himself  to  the  work  which  he  previously 
performed  with  ease  and  pleasure.  He,  furthermore, 
shrinks  from  new  undertakings  because  of  obstacles  which 
appear  unsurmountable. 

Under  the  influence  of  these  conditions,  the  emotional 
attitude  also  becomes  changed.  The  patients  become  easily 
flustered,  are  ill-humored,  unreasonable,  peevish,  faultfinding, 
irritable,  and  impetuous.  Customary  amusements  fail  to 
please,  and  they  become  discontented  with  their  occupation. 
Trifling  affairs,  like  the  misconduct  of  a  child,  inconven- 
iences at  work,  which  normally  would  pass  unnoticed,  disturb 
them  for  hours  and  even  days,  and  may  lead  to  impulsive 
outbursts,  which  they  later  regret. 

The  patients  have  not  only  a  keen  insight  into  these 
defects,  but  also  a  tendency  to  exaggerate  their  symptoms. 
They  assert  that  the  memory  is  becoming  profoundly  af- 
fected, and  that  the  judgment  is  failing.  The  physical 
symptoms  are  even  more  strongly  exaggerated,  which  aids  in 
increasing  their  misery.    The  excessive  anxiety  about  their 


150  FORMS  OF  MENTAL  DISEASE 

condition  of  health  leads  to  a  characteristic  symptom, 
hypochondriasis,  in  which  there  is  a  tendency  to  pay  undue 
attention  to  any  trifling  symptoms  that  may  be  present. 
They  believe  that  they  are  suffering  from  some  incurable 
disease,  and  especially  the  one  most  dreaded.  There  may 
be  some  genuine  disorder,  but  the  real  symptoms  are  greatly 
enhanced  by  the  attention  habitually  paid  to  them.  Canker 
in  the  mouth  is  considered  infallible  evidence  of  syphilis, 
a  cloudy  urine  indicates  Bright's  disease,  and  a  cough  means 
consumption.  In  the  beginning  these  fears  may  not  be  con- 
sidered in  a  very  serious  light,  but  when  they  interfere  with 
the  livelihood  of  the  patients  they  may  lead  to  such  feelings 
of  despair  that  the  patients  no  longer  hope  for  recovery, 
make  their  wills,  and  not  infrequently  attempt  suicide. 

The  appreciation  of  their  incapacity  creates  a  feeling 
of  reserve,  timidity,  and  a  lack  of  self-confidence.  They 
cannot  trust  themselves  in  public  and  fear  fainting  upon 
the  slightest  exertion.  Associated  with  the  loss  of  will- 
power, there  should  also  be  mentioned  the  tendency  to 
compulsive  thoughts  and  impulsive  acts,  which  sometimes 
explain  the  suicidal  attempts.  Here  are  included  the  vari- 
ous phobias,  which  are  fully  described  in  the  constitutional 
psychopathic  states.  In  the  strife  to  overcome  impulsive 
ideas,  the  patients  often  reach  an  emotional  crisis  of  short 
duration,  with  restlessness,  wringing  of  the  hands,  crying 
and  moaning,  and  even  attempts  at  suicide.  These  states 
are  more  apt  to  follow  continued  excitations,  such  as  pro- 
longed visits  or  unusual  noisiness. 

Physical  symptoms.  —  These  form  a  very  characteristic 
feature  of  the  psychosis.  Among  the  most  important  symp- 
toms are  headache,  insomnia,  general  muscular  weakness, 
paresthesias,  cardiac  and  gastro-intestinal  disturbances. 
Cephalalgia,  which  appears  early,  may  be  expressed  as  a 


ACQUIRED  NEURASTHENIA  151 

headache,  a  feeling  of  numbness  or  a  pressure  in  the  head, 
which  interferes  with  work.  This  is  usually  situated  over 
the  eyes  or  in  the  occiput,  and  increases  with  exertion  until 
it  becomes  unendurable.  It  is  more  prominent  in  the  morn- 
ing and  passes  off  during  the  day.  Sometimes  there  is  a 
feeling  of  pressure,  as  if  the  head  were  held  in  a  vice  or  by 
a  constricting  band.  It  may  be  associated  with  vertigo, 
dimness  of  vision,  roaring  in  the  ears,  or  painful  pressure 
points  in  the  scalp. 

Insomnia  is  usually  an  aggravating  symptom  from  the 
onset.  The  few  hours  of  sleep,  obtained  either  immediately 
upon  retiring,  or  in  the  early  morning,  after  hours  of  restless 
tossing,  are  unrefreshing  and  disturbed  by  dreams.  In  some 
cases,  there  is  an  unnatural  drowsiness  which  causes  the 
patients  to  fall  to  sleep  at  all  times  and  particularly  after 
some  exertion.  General  muscular  weakness  is  always  in 
evidence;  patients  are  always  languid,  and  tire  easily  upon 
walking  or  from  slight  muscular  effort. 

Both  the  superficial  and  deep  reflexes  may  be  increased. 
Rhythmic  twitchings  are  occasionally  noticed,  particularly 
twitching  of  individual  muscles  and  especially  those  of  the 
eye.  Moderate  stuttering  is  sometimes  complained  of. 
There  is  slight  tremor  of  the  eyelids  and  hands,  but  usually 
a  marked  fibrillary  tremor  of  the  tongue.  Subjective  sensa- 
tions, variously  located,  are  prominent,  such  as  paresthesias 
or  feelings  of  formication  in  the  trunk  and  limbs,  also  darting 
pains  and  burning  sensations. 

The  patients  are  usually  alarmed  by  various  cardiac  sen- 
sations ;  such  as  a  gnawing  or  burning  sensation,  palpitation 
and  precordial  pain  and  pulsations  in  different  parts  of 
the  body.  The  pulse  rate  varies  considerably  and  is  easily 
influenced  by  work  or  emotional  excitement.  Associated 
with  the  cardiac  disturbances  or  occurring  independently, 


152  FORMS  OF  MENTAL  DISEASE 

there  maybe  vasomotor  disorders;  as  cold  extremities,  local- 
ized sweating,  and  blushing  or  abnormal  dryness  of  the  skin. 

The  appetite  is  variable  and  anorexia  is  frequent,  but 
the  nervous  dyspepsia,  gastric  and  intestinal,  is  by  far  the 
most  prominent  digestive  disorder.  When  the  stomach  is 
empty,  there  is  usually  present  a  gnawing  sensation  which  is 
quickly  relieved  by  eating.  Gastric  fermentation,  probably 
due  in  part  to  deficiency  of  the  digestive  fluids,  especially 
hydrochloric  acid,  causes  distention  of  the  stomach,  ac- 
companied with  discomfort  and  pain.  Extending  into  the 
intestines,  the  fermentation  gives  rise  to  borborygmus  and 
colicky  pains,  the  latter  of  which  may  be  severe  enough  to 
simulate  genuine  colic.  The  digestion  is  usually  not  im- 
paired sufficiently  to  create  disturbances  of  nutrition,  but  in 
severe  cases  it  may  even  cause  cachexia  and  anaemia.  The 
bowels  are  usually  constipated  and  the  tongue  coated. 
Diarrhoeas  are  apt  to  appear  for  short  periods,  and  may  be 
persistent  for  a  considerable  time. 

In  the  sexual  life  there  is  more  often  a  loss  of  sexual  desire, 
but  in  a  few  cases  there  is  a  tendency  to  excessive  indul- 
gence, although  at  the  same  time  patients  may  complain  of 
impotence. 

In  those  cases  in  which  there  is  frequent  recurrence,  the 
patients  tend  to  become  chronic  invalids  of  a  most  distressing 
type.  They  go  the  round  of  physicians,  pass  from  one  sani- 
tarium to  another,  taking  all  kinds  of  drugs.  Mentally, 
they  pass  into  a  state  of  lethargy  in  which  all  thought  centers 
about  their  own  misery.  All  attempts  at  business  are  aban- 
doned, and  the  cares  of  the  household  are  renounced.  They 
betake  themselves  to  the  seclusion  of  a  charitable  institution 
with  its  freedom  from  annoyances,  or  if  they  remain  at  home, 
demand  the  utmost  consideration  for  every  whim.  They 
have  no  thought  for  the  maintenance  of  the  family  or  ap- 


ACQUIRED  NEURASTHENIA  153 

preciation  of  the  burden  which  they  create.  The  increasing 
demand  for  sympathy  leads  to  prevarications  and  to  various 
assumed  contortions,  in  order  to  assure  the  physicians  or 
friends  that  they  are  in  a  critical  condition.  The  daily 
greeting  from  one  patient  was,  "  My  God,  doctor,  I  am  dying  ! 
Just  feel  of  my  abdomen.  Have  you  no  compassion  for  a 
dying  man  ?  "  A  female  patient  remained  in  bed  for  years, 
and  when  received  at  the  hospital  from  the  hands  of 
a  tender-hearted  mother,  had  not  had  her  hair  combed 
in  two  years,  and  one  of  her  toe  nails  had  grown  to  the 
length  of  five  inches.  It  is  this  class  of  patients  who 
eventually  become  habitues  of  morphin,  cocain,  chloral, 
antipyrin,  and  other  drugs. 

Course.  —  The  onset  of  the  disease  is  gradual.  It  may, 
however,  develop  rapidly,  following  an  acute  illness,  especially 
influenza  and  also  childbirth.  There  is  a  great  variation  in 
the  prominence  of  the  symptoms.  A  daily  improvement 
toward  evening  is  characteristic.  Under  stress  of  circum- 
stances, the  patients  are  usually  able  to  pull  themselves  to- 
gether for  a  special  occasion,  but  the  following  day  witnesses 
an  exacerbation  of  the  symptoms.  The  course  is  often 
protracted  and  the  convalescence  gradual. 

Diagnosis.  —  The  differentiation  of  neurasthenia  from 
other  forms  of  mental  disease  is  of  the  greatest  importance 
because  of  its  bearing  upon  the  prognosis  and  treatment. 
In  the  first  place  it  is  necessary  to  exclude  organic  disease 
of  the  internal  organs.  The  diagnosis  of  neurasthenia  should 
rather  be  reached  by  a  process  of  exclusion,  after  a  most 
thorough  physical  examination. 

The  psychoses  most  apt  to  be  confounded  with  neuras- 
thenia are  dementia  paralytica,  dementia  praecox,  and  mel- 
ancholia of  involution.  The  difficulties  in  dementia  para- 
lytica arise  only  in  the  first  stages  of  the  disease.    Signs  of 


154  FORMS  OF  MENTAL  DISEASE 

nervousness  without  definite  cause  in  a  man  of  healthy  con- 
stitution, appearing  for  the  first  time  in  middle  life,  should  at 
least  arouse  suspicion  of  dementia  paralytica.  In  neuras- 
thenia the  alleged  memory  defect  varies  from  day  to  day, 
is  easily  corrected  upon  effort,  and  does  not  show  the  defective 
time  element  which  is  so  characteristic  of  the  defective  mem- 
ory in  the  paretic.  Neurastheniacs  complain  of  mental  im- 
pairment, but  are  able  to  amend  errors  in  writing  and 
speech,  while  the  real  mental  defect  in  the  paretic  is  unrecog- 
nized, or,  if  recognized,  its  extent  is  not  appreciated.  The 
defect,  therefore,  in  the  work  of  a  neurastheniac  is  quanti- 
tative, while  that  in  the  paretic  is  qualitative.  The  symp- 
toms of  the  neurastheniac  ameliorate  as  the  day  advances,  so 
that  the  evening  finds  him  at  his  best ;  on  the  other  hand,  the 
paretic  usually  awakens  refreshed,  and  more  capable,  but 
fatigues  more  during  the  day.  Again,  the  neurastheniac  has 
a  keen  insight  into  his  condition,  and  tends  to  exaggerate  his 
symptoms,  but  the  paretic  has  little  or  no  insight,  or,  if  pres- 
ent, he  rather  minimizes  than  exaggerates  his  symptoms. 
The  sensory  disturbances  of  the  neurastheniac  are  mostly 
subjective,  while  those  of  the  paretic  are  objective.  The 
presence  of  the  characteristic  physical  signs  of  paresis  should 
leave  no  doubt;  such  as,  Argyl  Robertson  pupil,  increased 
myotatic  irritability,  ataxia  in  speech  and  gait,  tremor  of 
the  facial  muscles  and  of  the  tongue,  epileptiform  or  apo- 
plectiform attacks,  etc. 

The  depressive  phases  of  the  other  psychoses,  especially 
dementia  prcecox  and  melancholia,  are  distinguished  with 
difficulty,  particularly  where  these  psychoses  follow  some 
acute  disease,  or  appear  in  neuropathic  individuals  who  have 
succumbed  in  the  struggle  with  more  favorably  endowed 
associates.  While  the  neurastheniac  is  ill-humored  and 
irritable  because  he  appreciates  that  his  mental  ability  is 


ACQUIRED  NEURASTHENIA  155 

impaired,  his  emotional  attitude  becomes  happier  just  as  soon 
as  some  external  excitement  or  a  jolly  company  allows  him 
to  forget  his  troubles,  or  as  soon  as  he  is  relieved  of  the  re- 
sponsibilities of  his  occupation,  and  can  secure  the  benefit  of 
rest  and  relaxation.  In  the  despondency  of  other  psychoses 
there  develops  a  feeling  of  anxiety  and  sadness  without  any 
good  reason,  which,  under  the  influence  of  distraction,  is 
not  only  not  alleviated  but  may  even  be  intensified.  The 
diminution  in  the  power  of  comprehension  and  the  ill-humor 
at  the  onset  of  dementia  prsecox  is  recognized  especially 
by  the  dulness  of  the  patient,  his  indifference  to  the  future, 
and  sometimes  also  by  the  senselessness  of  his  hypochon- 
driacal complaints. 

Where  the  external  causes  of  exhaustion  are  comparatively 
insignificant  one  naturally  suspects  that  there  is  at  the  bot- 
tom a  constitutional  nervous  weakness,  which  demands  not 
rest  and  relaxation  but  exercise  and  occupation.  While 
very  sharp  distinctions  cannot  be  drawn  between  these  states, 
yet  there  are  some  symptoms  in  congenital  neurasthenia 
which  are  rarely,  or  to  only  an  insignificant  degree,  found  in 
simple  neurasthenia;  namely,  the  great  susceptibility  of 
the  individual  symptoms  to  mental  suggestion,  especially 
the  abrupt  fluctuations  of  the  emotional  attitude,  the  anxious 
states,  and  the  lack  of  strength. 

Prognosis.  — The  prognosis  in  simple  nervous  exhaustion 
is  regarded  as  favorable,  but  it  depends  upon  the  extent  to 
which  the  exciting  causes  can  be  removed,  as  well  as  upon  the 
individual's  powers  of  resistance.  Under  proper  treatment 
most  patients  greatly  improve,  but  the  probability  of 
a  return  of  the  disease  sooner  or  later  becomes  much 
greater,  if  the  patient  must  enter  his  old  environment  and 
undertake  the  same  responsibilities  that  lead  to  the  first 
breakdown.     The   more   frequent   the  recurrence   of   the 


156  FORMS  OF  MENTAL  DISEASE 

disease,  the  less  liable  is  the  patient  ever  to  regain  his 
former  health. 

Treatment.  —  Where  possible,  it  is  the  duty  of  the  family- 
physician  to  bear  in  mind  prophylaxis.  Individuals  who 
are  handicapped  by  a  defective  heritage  must  be  well  guarded 
during  their  development,  with  due  attention  to  moral  and 
physical  hygiene.  Later,  when  it  becomes  necessary  to  enter 
actively  into  the  severer  duties  of  life,  the  limitation  of  men- 
tal application  and  physical  exertion,  together  with  the 
avoidance  of  worriment  and  anxiety,  must  be  constantly 
kept  in  mind. 

In  the  treatment  of  the  disease  after  its  development, 
the  individuality  of  the  physician  is  of  prime  importance; 
he  must  recognize  and  utilize  his  power  of  influence  over  the 
patient  in  addition  to  various  therapeutical  agencies.  It 
requires  confidence  in  order  to  inspire  the  patient  and  to  lift 
him  from  his  morbid  anxiety  and  depression.  Isolation  with 
a  changed  routine  of  life  demands  immediate  attention. 
In  the  lighter  cases  a  trip  to  the  mountains  or  a  sea  voyage 
to  relieve  the  asthenic  condition,  or  where  this  is  imprac- 
ticable, removal  from  the  customary  surroundings  into  a 
quiet,  restful,  but  attractive  place,  will  accomplish  the  same 
result. 

Next,  insomnia  must  be  combated.  Enforced  rest  in  bed 
with  change  of  environment,  removal  of  cares  and  relaxation, 
and  the  establishment  of  a  fixed  routine  usually  relieve  the 
sleeplessness.  At  any  rate,  one  should  not  have  to  employ 
sedatives  until  the  patient  has  had  a  chance  to  react  to  the 
new  method  of  life.  Before  resorting  to  the  use  of  drugs, 
the  simple  hypnotic  measures  should  be  exhausted ;  such  as, 
warm  liquid  nourishment  upon  retiring,  a  hot  bath,  gentle 
massage,  etc.  If  it  seems  necessary  to  resort  to  drugs,  then 
employ  the  triple  bromides  in  five-grain  doses  repeated  every 


ACQUIRED  NEURASTHENIA  157 

half  hour  for  five  doses  if  necessary,  administered  on  alter- 
nate nights  with  trional,  veronal,  or  somnos. 

Hydriatics  are  of  great  service  in  this  disease,  the  most 
serviceable  methods  being  the  cold  ablutions,  the  spray,  the 
simple  douche,  and  the  dripping  sheet.  In  the  last  method, 
which  may  be  carried  out  at  home,  after  a  cold  ablution, 
eighty-five  to  seventy-five  degrees,  the  patient  standing  in 
warm  water,  or  on  a  dry  surface,  with  a  cold  towel  about  the 
head,  a  linen  sheet  dipped  into  water  seventy-five  to  fifty- 
five  degrees,  is  wound  dripping  about  the  patient,  the  nurse 
at  the  same  time  applying  friction  until  a  thorough  reaction 
takes  place.  The  douche,  as  carried  out  at  bath  institutions, 
is  of  great  value. 

In  the  more  severe  cases,  the  secret  of  successful  treatment 
lies  in  a  well-regulated  routine  suited  somewhat  to  the  tastes 
of  the  individuals,  but  requiring  of  all  a  definite  amount 
of  sleep,  nourishment,  mental  and  physical  exercise,  alter- 
nated with  rest  and  relaxation,  together  with  baths  and  out- 
of-door  life.  All  of  this  may  be  carried  out  under  the  super- 
vision of  a  physician  who  is  willing  to  spend  time  and  thought 
in  attending  to  the  details.  The  relative  amount  of  exercise 
and  forced  rest  must  vary  in  individual  cases.  The  anaemic 
and  debilitated  who  have  been  exhausted  by  long  suffering 
or  the  prolonged  care  of  invalids,  together  with  anxiety  and 
worriment,  require  forced  rest  for  a  few  weeks  with  a  full 
nutritious  diet,  massage,  and  passive  movements.  Others, 
from  the  beginning,  need  graduated  daily  exercise,  which 
must  be  purposeful  and  suited  somewhat  to  the  tastes. 
The  diet,  also,  must  depend  upon  the  condition  of  the  nutri- 
tion. Where  indigestion  or  constipation  exists,  the  usual 
means  should  be  used  to  counteract  these  conditions,  always 
giving  preference  to  physical  agencies.  Electricity  and 
massage  are  of  value,  but  only  secondary  to  the  above 


158  FORMS  OF  MENTAL  DISEASE 

methods.  Sometimes  local  treatment  is  called  for  in  cor- 
recting uterine  troubles,  errors  of  optical  refraction,  or  in 
removing  nasal  obstructions. 

Finally,  the  patient  should  not  be  considered  suitable  for 
discharge  until  you  have  placed  her  beyond  the  danger  of 
relapse.  This  involves  on  her  part  a  thorough  understand- 
ing of  the  conditions  leading  to  her  breakdown,  and  requires 
an  inculcation  of  the  correct  principles  of  living  and  working 
and  an  appreciation  of  her  own  limitations.  Such  training 
should  be  established  early,  and  throughout  the  period  of 
treatment  no  opportunity  should  be  lost  in  impressing  these 
ideas  upon  her  mind. 


III.   INTOXICATION  PSYCHOSES 

The  term  intoxication  psychoses  is  here  used  in  a  narrow 
sense  to  include  all  psychoses  arising  from  toxic  substances 
taken  into  the  body. 

They  are  divided  into  acute  and  chronic  intoxications, 
according  to  the  length  of  the  time  during  which  the  toxic 
substances  have  been  ingested. 

1.  ACUTE  INTOXICATIONS. 

The  acute  intoxications  are  characterized  in  common  by 
&  delirious  state  of  short  duration,  with  pronounced  psy- 
chosensory disturbance,  dreamy  fantastic  delusions,  pleas- 
urable emotional  attitude,  often  with  conditions  of  ecstasy, 
and  without  much  motor  excitement. 

The  number  of  toxic  substances,  including  ptomaines, 
which  might  be  mentioned  here  is  large.  The  transitory 
character  and  the  infrequency  of  the  toxic  deliria  make 
them  of  little  importance  to  the  clinician.  They  are,  how- 
ever, of  great  scientific  value  to  investigators,  who  are 
able  to  study  pathologically  and  psychologically  the  effects 
of  the  different  toxic  substances.  Some  of  them  which 
are  characterized  by  peculiar  mental  symptoms  will  be 
mentioned  here.  The  mental  state  produced  by  chloro- 
form is  characterized  by  hallucinations  of  sight  only.  In 
santonin  poisoning  there  are  hallucinations  of  sight  in 
which  everything  appears  yellow;  hasheesh  delirium  is 
characterized  by  disturbance  of  the  taste  and  muscle  senses. 

Hasheesh  and  opium  smoking  produce  a  complacent  feel- 
ing of  well-being,  and  of  a  dreamy,  pleasurable  existence. 

159 


160  FORMS  OF  MENTAL  DISEASE 

The  carbonic  acid  narcosis  is  characterized  by  its  short 
duration  and  the  presence  of  pronounced  sexual  hallucina- 
tions. In  the  toxic  condition  produced  by  atropin  there 
is  a  severe  disturbance  of  apprehension,  with  isolated  hallu- 
cinations, marked  confusion  of  thought,  elated  emotional 
attitude,  and  active  motor  excitement.  The  course  is 
either  fatal  or  the  psychosis  clears  very  quickly  with  no 
recollection  of  the  events. 

The  duration  of  all  these  conditions  is  short,  from  a 
few  hours  to  a  few  days  at  the  most.  The  prognosis  de- 
pends entirely  upon  the  severity  of  the  intoxication.  In 
diagnosis  one  must  rely  in  great  measure  upon  the  knowl- 
edge of  the  circumstances  and  upon  the  physical  signs. 
The  treatment  is  limited  to  the  employment  of  means  to 
rid  the  body  of  the  toxic  substance,  and  the  application  of 
special  antidotes. 

The  psychosis  produced  by  lead  poisoning,  encephalo- 
pathia  saturninia,  is  more  frequent  and  differs  from  the 
above  delirious  states  by  its  longer  duration,  characteristic 
nervous  symptoms,  and  poorer  prognosis.  The  physical 
symptoms  usually  precede  the  mental  disturbance;  that  is, 
wrist  drop,  peroneal  paralysis,  tremor,  pains  in  the  limbs, 
and  sometimes  colic.  The  immediate  prodromes  are  rest- 
lessness and  headache.  The  onset  of  the  delirium  may  be 
acute  or  subacute.  There  are  many  hallucinations  of  sight 
and  hearing,  great  psychomotor  disturbance,  many  delusions 
with  great  fear,  and  complete  clouding  of  consciousness. 

The  speech  is  incoherent,  and  in  the  height  of  the  de- 
lirium there  are  frequent  reckless  impulsive  movements. 
There  is  complete  insomnia,  and  very  little  nourishment 
is  taken.  The  active  excitement  is  followed  by  a  condi- 
tion of  stupor  or  coma,  sometimes  antedated  by  stupor  with 
excitement. 


INTOXICATION  PSYCHOSES  161 

Epileptiform  convulsions  may  also  appear,  and  ambly- 
opia is  frequent.  The  convalescence  is  gradual,  extend- 
ing over  several  weeks.  Some  cases  terminate  fatally  in 
coma.  While  most  of  the  patients  recover,  there  are  many 
who,  upon  regaining  clear  consciousness,  present  a  degree 
of  mental  enfeeblement  in  which  simple  apathy  is  a  promi- 
nent feature.  A  few  present  progressive  muscular  atrophy, 
simulating  dementia  paralytica.  The  whole  duration  of 
the  psychosis  in  favorable  cases  is  from  a  few  weeks  to  three 
months. 


2.  CHRONIC  INTOXICATION 

Of  the  many  toxic  substances  whose  continued  use  leads 
to  disturbances  of  the  mind,  those  best  known  and  of  most 
clinical  value  are  alcohol,  morphin,  and  cocain.  Almost 
all  nations,  according  to  anthropological  data,  have  had  a 
drug  whose  habitual  use  has  been  a  source  of  danger  to  its 
people.  It  is  a  striking  fact  that  these  substances  have 
always  been  used  first  for  medical  purposes,  and  later  con- 
tinued for  their  exhilarating  and  alleged  supportive  effect. 

A.   Alcoholism 

The  acute  intoxication  of  alcohol  is  described  here  rather 
than  under  the  acute  intoxications,  because  of  its  close 
association  with  chronic  alcoholism. 

Acute  alcoholic  intoxication  produces  at  first  a  diminu- 
tion of  the  power  of  apprehension  and  elaboration  of  ex- 
ternal impressions,  and  an  acceleration  in  the  release 
of  voluntary  impulses.  The  perception  of  simple  sensory 
impressions  is  difficult,  sluggish,  and  uncertain.  An  attempt 
to  solve  a  simple  problem  shows  a  distinct  diminution  in 
intellectual  power. 

In  speech  one  can  discern  that  the  association  of  ideas 
most  closely  related  to  the  motor  elements  of  speech  is 
prominent,  such  as  the  use  of  compound  words  and  rhymes. 
The  release  of  motor  impulses  is  much  accelerated  so  that 
those  expressions  find  utterance  most  readily  that  are  most 
familiar.  The  choice  between  two  movements  is  precipitous, 
frequently  incorrect,  and  sometimes  already  executed  before 
the  proper  direction  is  determined  upon.     Later,  or  fol- 

162 


ACUTE  ALCOHOLISM  163 

lowing  larger  doses,  the  psychomotor  activity  is  displaced  by 
paralysis,  the  rapidity  and  extent  of  the  paralysis  depending 
both  upon  the  amount  taken  and  the  susceptibility  of  the 
individual.  The  muscular  strength,  at  first  slightly  in- 
creased, is  soon  much  diminished. 

Even  small  doses  influence  the  capacity  for  good  mental 
work.  Thoughts  are  not  easily  gathered,  rendering  the 
solution  of  complicated  problems  very  difficult .  This  in- 
creases with  the  amount  taken.  A  thoroughly  intoxi- 
cated man  is  unable  to  comprehend  what  is  said  to  him 
or  what  goes  on  about  him,  cannot  maintain  his  attention 
or  direct  the  train  of  thought.  He  has  no  conception  of 
the  significance  or  the  bearing  of  his  actions.  The  inter- 
nal association  of  the  train  of  thought  is  very  much  dis- 
turbed, as  indicated  by  the  tendency  to  the  repetition  of 
phrases  and  the  use  of  commonplace  remarks,  also  in  the 
fondness  for  quoting  obscene  rhymes  and  in  the  use  of 
jargon.  Finally  apprehension  may  be  so  far  lost  that  he 
becomes  insensible  and  unconscious.  Memory  of  events  of 
the  intoxicated  state  is  very  meagre. 

In  the  psychomotor  field,  at  first,  there  is  a  fight  grade 
of  overactivity,  with  the  disappearance  of  the  usual  re- 
straints which  regulate  the  actions  of  our  daily  lives.  He 
is  active,  gay,  free  and  jolly,  speaks  and  acts  without  re- 
straint, and  even  becomes  reckless.  The  ready  release 
of  motor  impulses  promotes  the  feeling  of  increased  mus- 
cular strength.  Later  the  motor  excitation  increases; 
the  facial  expression  loses  its  character,  each  action  is 
exaggerated;  the  voice  is  louder,  and  the  smile  broadens 
into  laughter.  He  becomes  profane,  grumbles,  and  growls. 
He  is  hasty  and  passionate,  and  a  single  wTord  or  a  trifling 
accident  suffices  to  start  a  quarrel  or  to  lead  to  an  assault. 
Finally  the  excitation,  as  the  disturbance  of  apprehension 


164  FORMS  OF  MENTAL  DISEASE 

increases,  is  replaced  by  signs  of  paralysis,  and  there  is  a 
profound  disturbance  of  speech,  a  staggering  gait,  and  even 
complete  motor  paralysis. 

The  emotions  at  first  give  way  to  a  feeling  of  well-being. 
There  is  a  certain  degree  of  exhilaration,  and  freedom 
from  care.  He  becomes  light-hearted  and  happy.  Later 
irritability  appears.  Higher  moral  feelings  are  lost.  He 
is  shameless,  and  because  of  the  increased  sexual  excita- 
bility is  often  led  to  filthy  excesses. 

The  duration  of  the  intoxication  depends  much  upon 
the  individual.  It  usually  disappears  quite  rapidly,  al- 
though ill  effects  may  be  observed  for  twenty-four  to  thirty- 
six  hours  later:  headache,  lassitude,  nausea,  and  anorexia. 
Fatigue  predisposes  to  rapid  appearance  of  paralytic  signs, 
even  without  the  intervention  of  the  period  of  excitation. 
Individuals  who  are  rendered  sluggish  and  sleepy  are  apt 
also  to  be  quarrelsome,  aggressive,  mischievous,  and  even 
cruel. 

As  the  result  of  experimental  investigations  of  acute  in- 
toxication in  test  animals,  Nissl  has  demonstrated  a  profound 
change  in  the  cortical  neurones,  seen  in  the  destruction  of 
many  cells,  in  the  fading  and  the  irregular  amalgamation 
of  the  Nissl  granules,  the  diminution  in  size  and  irregularity 
of  the  nucleus,  whose  membrane  and  nucleolus  may  finally 
disappear.  Dehio  has  observed  similar  changes  in  Purkinje 
cells. 


Chronic  Alcoholism 

Chronic  alcoholic  intoxication  depends  upon  a  chronic  de- 
generative process  in  the  central  nervous  system,  and  is 
characterized  by  a  gradually  progressive  dementia,  with  di- 
minished capacity  for  work,  faulty  judgment,  defective  memory, 
moral  deterioration,  occasional  delusions,  infrequent  halluci- 
nations, and  various  nervous  symptoms. 

Etiology.  —  Defective  heredity  is  an  important  etio- 
logical factor,  and  is  manifested  by  a  diminished  power  of 
resistance  in  the  individual.  Some  observers  have  re- 
ported as  high  as  eighty  per  cent,  of  cases  with  defective 
heredity,  in  at  least  one-half  of  whom  the  father  had  been  a 
chronic  drinker.  Head  injury,  according  to  Moli,  in  twenty- 
two  per  cent,  of  the  cases,  has  been  regarded  as  a  factor 
in  producing  lessened  resistance  to  alcohol.  Male  alcoholics 
greatly  predominate.  At  Heidelberg  only  six  per  cent,  were 
women.  Hirschl,  in  Vienna,  found  among  the  male  insane 
thirty  per  cent,  alcoholics  and  among  the  women  only  four 
per  cent,  alcoholics.  Alcoholism  is  more  prevalent  among 
those  who  come  in  contact  with  it,  especially  the  bartenders, 
liquor  dealers,  brewers,  and  waiters.  The  extensive  use  of 
alcoholic  drinks  by  many  classes  of  society  and  the  laxness 
of  public  sentiment  in  regard  to  it  should  also  be  regarded 
as  etiological  factors.  Furthermore,  the  ignorance  of  most 
people  as  to  its  proven  deleterious  effects  is  in  a  measure  an 
important  element.  There  are  thousands  upon  thousands 
who  daily  take  a  little  beer,  wine,  or  liquor  because  they  are 
convinced  that  "  it  does  them  good,"  and  strengthens  them. 

Pathological  Anatomy. — In  the  brain,  in  advanced  cases, 
there  is  regularly  more  or  less  chronic  leptomeningitis  and 
pachymeningitis  with  or  without  haematoma.  The  cere- 
brum is  below  normal  in  weight,  its  convolutions  more  or  less 

165 


166  FORMS  OF  MENTAL  DISEASE 

shrunken,  and  its  ventricles  dilated,  the  ependyma  of  which 
in  rare  instances  is  granular.  The  larger  vessels  at  the  base 
and  in  the  fissures  present  arteriosclerotic  patches  or  athe- 
roma, but  the  most  characteristic  lesion  is  the  endarteritis, 
mostly  localized,  of  the  small  terminal  arteries  of  the 
cortex  and  other  parts  of  the  brain.  The  cortical  neurones 
present  a  gradual  sclerosis,  called  the  "  chronic  change 
of  Nissl."  Nissl,  in  his  experimental  research  with  chronic 
alcoholism,  in  test  animals,  found  a  moderate  thickening  of 
the  pia,  especially  at  the  base,  destruction  of  many  of  the 
cortical  neurones,  with  an  increase  of  neuroglia,  and  besides 
these  other  extensive  characteristic  cortical  changes,  the 
meaning  of  which  is  still  unknown.  Alterations  in  the  in- 
ternal organs  are  equally  prominent;  namely,  chronic 
gastritis,  cirrhosis  of  the  liver,  chronic  nephritis,  fatty  in- 
filtration of  the  myocardium,  and  chronic  endocarditis  with 
greater  or  less  degree  of  general  arteriosclerosis. 

Symptomatology.  —  There  is  a  gradual  and  progressive 
enfeeblement  of  the  intellectual  faculties.  The  capacity  for 
work  is  first  to  suffer.  The  power  of  mental  application 
gradually  fails,  it  becomes  difficult  to  maintain  the  attention, 
and  the  susceptibility  to  fatigue  increases.  New  and  unac- 
customed work  requires  unusual  application  and  is  accom- 
plished only  with  difficulty.  Patients  prefer  to  continue  in  the 
same  old  ruts,  and  are  indifferent  in  applying  themselves  to 
any  mental  work .  Consequently  intellectual  development  not 
only  ceases,  but  retrogrades,  showing  an  increasing  lack  in 
judgment  and  a  poverty  of  ideas,  enhanced  by  a  gradual  fail- 
ure of  memory.  Finally  there  is  inability  to  acquire  anything 
new,  important  facts  are  forgotten,  and  the  past  is  recalled 
only  as  a  somewhat  confused  and  distorted  picture.  The 
defects  of  judgment  and  memory  offer  a  fertile  soil  for  the  de- 
velopment of  numerous  more  or  less  pronounced  delusions. 


CHROiNIC  ALCOHOLISM  167 

These  delusions  tend  to  show  a  striking  lack  of  judgment,  are 
peculiarly  ideas  of  injury,  which  sometimes  take  their  origin 
from  isolated  hallucinations,  but  more  frequently  from  gen- 
uine perceptions  which  are  falsely  interpreted.  In  the 
more  severe  cases,  a  condition  of  advanced  deterioration  is 
reached. 

Moral  deterioration  is  a  prominent  and  characteristic 
symptom.  There  is  a  profound  change  in  moral  character, 
and  the  patients  soon  lose  sight  of  the  higher  ideals  of  life 
and  the  sense  of  honor.  This  is  especially  noticeable  in 
their  own  estimation  of  their  alcoholic  habits.  They  dis- 
regard their  depravity  with  nonchalance,  and  claim  that  the 
liquor,  taken  for  their  physical  benefit,  does  them  no  harm. 
When  reprimanded  for  continued  inebriety,  they  accuse  a 
friend  of  having  given  them  the  liquor,  or  claim  that  they 
are  driven  to  drink  by  their  wives.  A  faithful  promise  to 
abstain  from  further  use  of  alcohol  may  be  volunteered 
by  an  habitue ;  but  when  encountered  coming  from  a 
saloon  an  hour  later,  he  fails  to  show  any  feeling  of 
shame. 

Some  claim  that  their  work  necessitates  stimulation; 
others  take  only  as  much  as  can  be  regarded  as  a  food.  It  is 
of  interest  to  note  the  variety  of  conflicting  excuses  offered 
by  mechanics  for  the  necessity  of  taking  liquor:  the  cook, 
the  fireman,  and  the  iron  moulder  require  it  because  of  the 
great  heat;  while  the  night  watchman,  the  truckman,  and 
the  iceman  need  it  to  keep  off  the  cold.  Many  are  driven 
to  drink  by  unfortunate  circumstances  at  home;  the  death 
of  a  relative,  a  sick  child,  and  an  ugly  wife  are  frequent 
incentives. 

The  patients  lose  all  affection  for  their  families,  become 
indifferent  to  the  tears  of  their  children,  have  little  interest 
in  their  welfare,  disregard  the  real  infidelity  of  their  wives, 


168  FORMS  OF  MENTAL   DISEASE 

at  the  same  time  developing  a  certain  exaggerated  feeling  of 
self-importance,  noticeable  especially  in  conversation.  They 
are  unable  to  take  matters  seriously,  and  display  an  un- 
natural sense  of  humor,  —  drunkard's  humor. 

There  is  a  corresponding  increase  of  emotional  irritability, 
which  is  more  evident  during  intoxication.  Patients  are 
quarrelsome,  engage  in  strife  and  abuse  on  small  provoca- 
tion, misuse  their  children,  and  are  destructive  of  clothing 
and  furniture.  Their  complete  and  abject  submission  when 
opposed  by  a  superior  force  or  when  incarcerated  is  in 
marked  contrast  to  their  behavior  at  home.  Their  in- 
offensive behavior  and  attitude  of  humiliation  before  others 
often  excites  sympathy  from  the  inexperienced. 

They  become  entirely  unstable,  cannot  remain  at  home, 
visit  from  saloon  to  saloon,  tramp  from  one  city  to  another, 
and  engage  in  their  usual  occupation  only  for  a  few  days  or 
hours  at  a  time,  offering  the  excuse  that  they  are  physically 
unfit  for  continued  labor.  They  leave  the  support  of  the 
family  to  the  wife  and  children,  whom  they  browbeat  for 
enough  money  to  keep  them  in  liquor.  Others  degrade 
themselves  by  pawning  clothing  and  furniture,  and  even  steal 
in  order  to  satisfy  their  appetite. 

Physically.  —  The  most  prominent  physical  symptoms 
are:  fine  tremor,  noticed  first  in  the  more  delicate  move- 
ments and  later  becoming  general ;  muscular  weakness  with 
atrophy;  uncertainty  in  gait;  defective  speech,  sometimes 
thick,  sometimes  slurring,  with  occasional  aphasic  symptoms; 
peripheral  neuritis;  frequent  headaches  and  sometimes  ver- 
tigo. The  tendon  reflexes  are  often  increased,  rarely  lost. 
In  the  sensory  field  there  are  frequently  found  areas  of 
hyperesthesia,  anaesthesia,  paresthesia,  as  well  as  painful 
pressure  points.  Epileptoid  attacks  occur  in  about  ten  to 
thirty-five  per  cent,  of  the  cases,  usually  during  an  attack  of 


CHRONIC  ALCOHOLISM  169 

delirium  tremens  or  at  the  conclusion  of  a  spree,  but  also 
during  the  course  of  chronic  alcoholism  and  even  after  more 
or  less  prolonged  abstinence.  They  occur  mostly  in  persons 
addicted  to  distilled  liquors,  and  differ  from  genuine  epileptic 
attacks  in  that  they  are  infrequent,  but  unusually  severe, 
while  the  absences,  ill-temper,  and  befogged  states  peculiar 
to  epilepsy  are  absent.  Furthermore,  the  epileptic  attacks 
usually,  but  not  always,  disappear  with  enforced  abstinence. 

In  the  sexual  life  there  gradually  develops,  in  spite  of  in- 
creased sexual  irritability,  impotency  which  often  leads  to 
jealousy  and  fornication.  Furthermore,  the  progeny  is 
rendered  not  only  susceptible  to  alcoholism,  but  is  particu- 
larly apt  to  exhibit  evidences  of  defective  physical  and  men- 
tal development,  and  also  epilepsy.  The  rate  of  mortality 
of  the  children  of  alcoholic  mothers  is  twice  as  great  during 
the  first  two  years  of  life  as  of  non-alcoholic  mothers.  This 
rate  also  increases  with  successive  childbearing,  reaching  as 
high  as  seventy- two  per  cent. 

Prognosis.  —  The  chances  of  recovery  depend  upon  the 
extent  of  mental  deterioration  and  the  character  of  the 
treatment.  If  the  patients  already  show  moral  deteriora- 
tion, prolonged  treatment  is  apt  to  be  of  little  avail;  each 
time  they  relapse  into  their  former  habits,  becoming  at  last 
mental  and  physical  wrecks.  Cases  when  taken  early  and 
submitted  to  an  extended  treatment  have  a  fair  prospect 
of  complete  recovery.  In  many  reputable  inebriate  institu- 
tions from  one-fourth  to  one-third  of  their  cases  recover 
permanently. 

Diagnosis.  —  The  recognition  of  chronic  alcoholism  pre- 
sents few  difficulties  in  view  of  the  history,  the  typical 
facies,  and  the  physical  symptoms,  the  latter  being  at  times 
made  more  evident  by  the  presence  of  neuritic  symptoms. 

Treatment.  —  The  successful  treatment  of  chronic  alco- 


170  FORMS  OF  MENTAL  DISEASE 

holism  demands  complete  abstinence  from  alcohol  in  every 
form.  A  few  patients  are  capable  of  carrying  out  this  in- 
junction successfully  by  themselves,  but  the  vast  majority, 
and  especially  those  whose  occupation  brings  them  into  bad 
associations,  require  the  treatment  afforded  by  a  special 
institution  for  alcoholics.  The  success  of  this  or  any  other 
plan  of  treatment  in  the  chronic  alcoholic  is  materially 
impeded  by  the  general  indifference  of  the  environment  and 
the  attitude  of  physicians.  Very  many  physicians,  wholly 
ignorant  of  the  favorable  results  of  treatment  in  reputable 
institutions,  injudiciously  advise  the  friends  that  it  is  of 
no  use  to  waste  money  in  a  long  sojourn  at  an  institution. 
Even  institution  physicians  are  not  beyond  criticism  in  this 
respect,  and  will  force  the  patient's  discharge  "  as  soon  as 
the  drink  is  out  of  him."  If  the  patient  himself  does  not 
appreciate  the  necessity  of  treatment  or  because  of  delusions 
resists  any  restriction  of  his  liberty,  then  one  must  resort 
to  a  legal  commitment  to  an  institution,  which  is  now  possible 
in  many  states  even  for  a  period  of  two  years. 

As  soon  as  the  patient  is  committed  to  your  care  the  alco- 
hol can  be  suddenly  withdrawn,  except  in  a  few  cases  where 
there  is  a  disturbance  of  the  heart.  The  abstinence  symp- 
toms, insomnia,  anorexia,  and  occasional  hallucinations, 
which  arise  in  consequence  of  withdrawal,  tend  to  quickly 
disappear,  and  should  cause  no  alarm.  Improvement  begins 
in  a  few  days,  and  progresses  gradually.  If  the  patient 
is  received  in  a  condition  of  drunkenness,  ergot  administered 
in  fifteen-minim  doses  and  repeated  every-  two  hours,  or 
apomorphin  given  hypodermically,  beginning  with  -£$  grain 
and  repeated  until  vomiting  sets  in  and  the  patient  falls  to 
sleep,  are  remedies  well  recommended  to  ward  off  delirium 
tremens  and  to  restore  the  equilibrium  of  the  patient.  But 
for  the  benefit  of  the  psychical  effect,  it  is  sometimes  ad- 


CHRONIC  ALCOHOLISM  171 

vantageous  for  the  patients  not  to  be  relieved  of  all  suffer- 
ing. Severe  cases  require  a  hospital  residence  of  nine  to 
twelve  months,  or  even  longer.  An  index  of  the  power  of 
resistance  may  be  found  in  the  patients'  insight  into  their 
own  condition,  and  willingness  to  prolong  hospital  treat- 
ment. 

In  light  cases  it  sometimes  suffices  to  place  the  patient  to 
live  in  a  family  and  community  where  total  abstinence  pre- 
vails. Even  here  it  is  necessary  that  the  patient  be  kept 
under  close  surveillance,  especially  during  the  first  few 
months.  A  similar  arrangement  is  sometimes  an  excellent 
plan  to  adopt  for  a  time  after  discharge  from  an  institution, 
particularly  where  the  patient  has  to  return  to  an  unfavor- 
able environment.  Hypnotic  suggestion  has  been  very  suc- 
cessful in  the  hands  of  some  physicians,  both  in  establishing 
a  disgust  for  liquor  and  in  creating  will  power  to  combat 
the  habit  and  withstand  the  enticements.  Its  employment, 
if  successful,  permits  the  patient  to  remain  at  work  and  with 
the  family,  rendering  unnecessary  a  prolonged  and  expen- 
sive sanitarium  residence.  Much  depends  upon  the  per- 
sonality of  the  physician  in  charge  of  the  patient  or  the 
individual  at  the  head  of  the  family,  who  must  inculcate 
the  principles  of  temperance  and  rehabilitate  the  powers  of 
resistance.  A  very  important  means  for  the  assistance  of 
the  patient  in  his  struggle  against  the  alcoholic  habit  are 
the  various  temperance  abstinence  societies,  the  most  power- 
ful of  which  in  this  country  are  the  Temperance  Abstinence 
Society  of  the  Catholic  Church  and  the  Good  Templars. 

Upon  the  basis  of  chronic  alcoholism,  there  develops  a 
series  of  characteristic  psychoses :  namely,  delirium  tremens, 
Korssakow's  psychosis,  acute  alcoholic  hallucinosis,  alcoholic 
hallucinatory  dementia,  alcoholic  paranoia,  alcoholic  paresis, 
and  alcoholic  pseudopareses. 


Delirium  Tremens 

Delirium  tremens  is  characterized  by  the  rather  sudden 
development  of  numerous  fantastic  hallucinations,  mostly  of 
sight  and  hearing,  indefinite  and  changing  delusions,  principally 
of  fear  and  often  of  a  religious  nature,  with  clouding  of  con- 
sciousness, restlessness,  tremor,  ataxic  disturbances,  with  rapid 
course  and  good  prognosis. 

Etiology.  —  The  etiology  of  delirium  tremens  is  by  no 
means  thoroughly  understood.  In  the  greater  number  of 
cases  excessive  alcoholism  appears  to  be  the  important  factor, 
though  it  is  generally  recognized  that  the  disease  may  de- 
velop in  connection  with  an  acute  febrile  disease  or  some 
pronounced  emotional  excitement,  as  imprisonment  and 
injury.  Careful  analyses  of  cases  tend  to  show  that  bodily 
injury  is  really  significant  in  not  more  than  five  to  ten  per 
cent,  of  cases,  while  the  disease,  pneumonia,  occurs  far  more 
frequently  (Bonhoeffer  forty  per  cent.).  It  seems  probable, 
therefore,  that  in  chronic  alcoholics,  any  disturbance  which 
overtaxes  the  functional  activity  of  the  body  or  disturbs  its 
equilibrium  tends  to  produce  delirium  tremens;  thus,  severe 
chronic  disturbances  of  the  general  nutrition  are  of  great  im- 
portance among  the  predisposing  factors,  such  as  that  arising 
from  gastritis,  which  occurs  in  most  cases  and  prevents  the 
taking  of  sufficient  food  for  many  weeks  and  even  months. 
Furthermore,  the  symptoms  of  delirium  tremens  in  no  way 
resemble  those  of  acute  alcoholic  intoxication,  hence  the 
delirium  cannot  be  due  to  alcoholic  intoxication  alone. 
Again,  the  amount  of  alcohol  ingested  immediately  before 
the  attack  seems  to  bear  no  definite  relation  to  it,  as,  in 
some  cases,  the  patients  have  had  no  alcohol  for  weeks; 
others  develop  the  condition  only  upon  its  withdrawal,  and 
in  some  it  appears  in  spite  of  continued  drinking.  In  the 
development  of  delirium  tremens,  other  particular  factors 

172 


DELIRIUM  TREMENS  173 

must  be  at  work  besides  the  excessive  use  of  alcohol.  Just 
what  they  are  is  not  definitely  known.  It  is  believed  that 
the  numerous  and  severe  organic  changes  accompanying 
chronic  alcoholism  play  an  important  role  and  undoubtedly 
produce,  as  shown  by  the  poverty  of  the  blood  and  abun- 
dance of  adipose  tissue,  profound  disturbances  of  metabolism. 
Jacobson  points  to  the  presence  of  a  decomposition  material 
in  the  intestine;  Hertz  places  delirium  tremens  on  the  same 
basis  as  uraemia;  Elsholz  finds  blood  changes  indicative 
of  a  particular  auto-intoxication;  and  Bonhoeffer  suggests 
an  intoxication  arising  out  of  the  process  of  digestion,  the 
product  of  which  is  normally  secreted  by  the  lungs,  which 
intoxication  is  particularly  apt  to  develop  when  the  lungs 
become  diseased,  as  so  frequently  happens  in  delirium 
tremens.  But  the  findings  in  the  blood  and  urine,  which 
result  directly  from  the  action  of  the  alcohol  or  indirectly 
through  the  fever,  also  the  frequent  occurrence  of  fever  and 
finally  the  characteristic  mental  picture,  point  conclusively 
to  the  fact  that  in  delirium  tremens  we  have  to  do  not  only 
with  the  simple  increase  of  the  chronic  alcoholic  intoxication, 
but  with  an  essentially  different  sort  of  an  intoxication  to  which 
the  excessive  alcoholism  is  only  a  predisposing  factor.  The 
common  occurrence  of  abortive  attacks  of  delirium  tremens, 
preceding  for  some  time  the  genuine  attack  of  delirium 
tremens,  seems  to  distinctly  favor  this  view,  and  to  point  to 
the  additional  fact  that  in  delirium  tremens  there  is  only  a 
sudden  increase  of  disturbances  which  have  been  present 
some  time,  but  in  a  milder  degree. 

Male  patients  greatly  predominate  in  delirium  tremens. 
According  to  Bonhoeffer  seventy-four  per  cent,  of  cases  occur 
between  thirty  to  fifty  years  of  age.  The  disease  occurs  more 
frequently  in  summer  than  in  winter. 

Pathological  Anatomy.  —  Besides  a  pronounced  degree  of 


174  FORMS  OF  MENTAL  DISEASE 

venous  stasis  and  edema  of  the  brain,  which  is  usually  pres- 
ent, Bonhoeffer  !  finds  a  marked  degree  of  fibre  atrophy  in 
the  radial  fibres  of  the  central  convolution,  in  the  fibre- 
tracts  of  the  worm  of  the  cerebellum,  and  especially  in  the 
columns  of  Goll  in  the  cord,  while  there  is  little  or  no  altera- 
tion in  the  parietal  or  Broca  convolutions;  these  lesions 
are  not  found  in  simple  alcoholism.  In  the  large  pyramidal 
cells  and  in  the  motor  cells  of  the  anterior  central  convolu- 
tions, the  outline  of  the  unstainable  substance  is  more  or  less 
completely  lost,  and  the  processes  are  markedly  stained  for 
a  considerable  distance.  Occasionally  nuclear  changes  are 
observed.  A  number  of  cells  appear  to  be  destroyed.  A 
similar  condition  prevails  among  the  Purkinji  cells.  Nissl 
calls  attention  to  a  partial  destruction  of  the  cortical  cells, 
and  to  a  cell  change,  which  is  suggestive  of  other  acute  cell 
changes,  in  which  there  is  staining  of  the  achromatic  sub- 
stance, especially  the  axis  cylinder  processes,  vacuolization  in 
the  cell  substance  and  moderate  swelling,  besides  chronic 
cell  changes  and  an  increase  of  glia.  A  part  of  these  changes 
are  due  to  chronic  alcoholism,  among  which  should  be  added 
miliary  hemorrhages,  which  in  places  occur  in  great  numbers, 
particularly  about  the  nuclei  of  the  eye  muscles,  as  well  as 
certain  vascular  changes.  In  the  internal  organs  there  are 
found  fatty  degeneration  and  fibroid  myocarditis  of  the  heart, 
cirrhosis  of  the  liver,  and  acute  and  chronic  alterations  in 
the  kidneys.  Furthermore,  Jacobson  discovered  in  forty- 
five  of  seventy-two  autopsies  an  acute  hyperplasia  of  the 
spleen,  and  in  nine  cases  a  hyperemia. 

Symptomatology.  —  Among  the  first  symptoms  to  appear 
are  the  sense  deceptions;  illusions  and  hallucinations  of  all 
the  senses,  but  more  especially  of  sight  and  hearing.    These 

1  Bonhoeffer,  Monatsschr.  f.  Psychiatrie  u.  Xeurologie,  I,  229;  Troem- 
ner,  Archiv  f.  Psychiatrie,  XXXI,  3. 


DELIRIUM  TREMENS  175 

appear  at  first  during  the  day  and  annoy  the  patients  con- 
stantly. They  are  perceived  with  great  clearness,  and  with 
the  terrifying  content  produce  a  marked  alteration  in  the 
emotions.  The  patients  see  all  sorts  of  animals,  large  and 
small,  moving  about  them;  rats  scamper  about  the  floor, 
serpents  crawl  over  the  bedding,  insects  cover  their  food, 
and  birds  of  prey  hover  about  in  the  air.  These  forms  almost 
always  show  more  or  less  active  movement,  depending  upon 
the  restlessness  of  the  body  and  the  eye  movements.  Double 
sight  is  sometimes  observed.  This  unsteadiness  may  in  a 
measure  account  for  the  frequency  with  which  the  flitting 
and  scurrying  animals  appear.  Fantastic  forms  are  seen,  — 
mermaids,  satyrs,  and  huge  quadrupeds.  Crowds  press 
upon  them,  troops  file  by.  The  devil  and  his  imps  are 
omnipresent,  peering  in  at  the  windows  or  crawling  from 
under  the  bed. 

The  patients  hear  all  sorts  of  noises, — the  roaring  of  beasts, 
ringing  of  bells,  firing  of  cannons,  crying  of  distressed  chil- 
dren. They  are  taunted  by  passing  crowds,  are  threatened 
with  death,  are  cursed,  called  traitors,  thieves,  and  mur- 
derers. Paresthesias  of  the  skin  lead  to  the  ideas  that 
ants  are  crawling  over  them,  that  bullets  have  entered  the 
body,  and  even  the  absence  of  wounds  does  not  deter  them 
from  exposing  limbs  which  have  been  shot  full  of  missiles. 
Hot  irons  are  being  applied  to  their  backs,  and  dust  is 
thrown  in  their  faces.  They  can  detect  the  odor  of  gas, 
sulphur  fumes  are  being  forced  through  the  keyhole.  Real 
objects  about  the  room  assume  life;  the  tufts  on  the  bedding 
become  creeping  things,  and  the  bedposts,  demon  guards. 
The  content  of  the  hallucinations  is  not  always  of  a  terrify- 
ing nature.  Sometimes  angels  are  seen;  beautiful  music  is 
heard.  God  appears  to  them,  announcing  that  they  are 
Christs,  and  empowered  to  cast  out  devils;  they  are  com- 


176  FORMS  OF  MENTAL  DISEASE 

manded  to  go  to  confession  and  to  proclaim  the  gospel 
message;  they  are  in  beautiful  surroundings,  are  richly 
dressed,  in  palatial  quarters,  attended  by  lovely  maidens. 
Sometimes  the  scenes  are  of  a  lascivious  character.  Occa- 
sionally there  is  a  mixture  of  the  fearful  and  the  beautiful, 
but  more  often,  when  there  is  a  change  of  the  emotions,  the 
former  is  gradually  replaced  by  the  latter,  as  the  course  of 
the  disease  progresses.  The  hallucinations  in  a  few  cases, 
and  especially  after  the  height  of  the  disease  has  been  passed, 
are  nothing  more  than  a  passing  show  for  the  patients;  they 
then  gaze  at  the  hideous  forms  and  listen  to  the  various 
noises  quite  unconcerned. 

The  results  of  various  experiments  seem  to  indicate  that 
the  hallucinations  and  illusions  originate  in  disturbances  of 
the  central  processes.  Hallucinations  seen  through  a 
colored  glass  are  not  similarly  colored.  Also  the  hallucina- 
tions can  be  made  to  appear  by  directing  the  patient's 
attention  to  their  sensory  fields,  and  by  asking  them  what 
they  see  and  hear. 

The  various  hallucinations  may  enter  into  the  picture  of 
an  occupation  delirium,  when  the  patient  is  busy  gathering 
up  the  gold  lying  about  him,  driving  a  flock  of  sheep,  lead- 
ing an  orchestra,  or  addressing  an  audience.  On  the  basis 
of  these  delirious  experiences,  the  patients  may  develop  a 
whole  fabric  of  delusions  concerning  their  environment  and 
their  experiences,  but  these  delusions  are  never  elaborated, 
do  not  influence  the  thought  or  action  to  any  extent,  and  are 
quickly  forgotten.  There  never  develop  delusional  ideas  in 
reference  to  the  personality  of  the  individual.  The  patients 
always  know  who  and  what  they  are. 

The  process  of  perception  in  itself,  according  to  BonhoerTer,1 
does  not  present  any  very  striking  disturbances,  the  pain, 
1  Bcmhoeffer,  Der  Geisteszustand  der  Alcoholdeliranten,  1897. 


DELIRIUM  TREMENS  177 

muscular  and  temperature  sense  of  the  skin,  as  well  as  the 
acuity  of  sight  and  hearing  and  the  measuring  of  distances 
by  the  eye,  being  normal.  The  field  of  vision  is  sometimes 
restricted,  the  recognition  of  color  is  uncertain,  and  the 
tactile  sensibility  on  the  finger  tips  and  the  forehead  is  in- 
creased. The  sense  of  equilibrium  is  sometimes  very  greatly 
disturbed,  many  patients  being  unable  to  sit  up,  to  stand 
or  walk,  and  very  anxious  to  remain  in  bed.  This,  he  be- 
lieves, accounts  for  the  disorientation  of  the  body  in  space. 
Patients  frequently  complain  that  the  floor  is  shrinking 
and  that  the  walls  are  coming  together,  which  may  be  due 
to  disturbances  of  the  eye  muscles  or  of  the  labyrinthine 
sense. 

Disturbances  of  apprehension  are  prominent.  There  is 
defective  interpretation  of  the  impressions  excited  in  the 
various  sensory  fields,  with  the  result  that  the  patients  mis- 
interpret noises,  do  not  recognize  pictures,  and  are  unable 
to  obtain  any  sharp  and  clear  impressions.  The  disturbance 
becomes  more  apparent  when  the  patients  attempt  to  read. 
Instead  of  correct  sentences,  they  read  a  senseless  series  of 
words  and  sound  associations,  noticeable  especially  when 
the  type  is  small  and  indistinct.  Sometimes  there  is  no 
relation  at  all  between  the  reading  and  the  subject-matter. 
This  same  defect  is  sometimes  due  to  aphasic  disturbances. 

The  attention  also  shows  marked  disturbance.  While  it  is 
possible  to  hold  the  attention  for  a  moment,  —  for  instance, 
long  enough  to  get  a  response  to  your  reading  test,  —  at  the 
next  the  attention  fails  in  spite  of  your  efforts.  The  pro- 
nounced disturbance  of  attention  makes  the  disturbance  of 
apprehension  appear  even  greater  than  what  it  is.  Forcible 
language  may  hold  the  patients  for  a  short  time,  but  they 
usually  relapse,  and  they  note  only  those  objects  that 
especially  attract  them. 


178  FORMS  OF  MENTAL  DISEASE 

There  is  always  a  moderate  clouding  of  consciousness.  The 
surroundings  are  not  correctly  comprehended,  and  the  ideas 
which  are  excited  by  occurrences  in  their  immediate  sur- 
roundings are  confused  and  contradictory.  The  greater 
degrees  of  insensibility  are  found  only  in  severe  cases  and 
especially  following  epileptoid  attacks.  On  the  other  hand, 
there  is  profound  disturbance  of  orientation,  except  in  the 
lightest  cases.  The  surroundings  are  mistaken  for  the  bar- 
room, the  church,  or  the  prison,  and  strangers  are  greeted 
as  old  friends.  Time  orientation  is  also  incorrect.  Usually 
the  duration  of  the  illness  seems  to  the  patients  much 
prolonged,  even  to  months. 

The  memory  for  remote  events  is  well  retained.  The 
patients  recall  correctly  where  they  live  and  facts  concern- 
ing their  families  and  occupation,  and  the  length  of  time 
they  may  have  resided  in  different  places.  But  the  im- 
pressibility of  the  memory  is  greatly  impaired,  as  may  be 
determined  by  giving  the  patients  a  series  of  words  or  num- 
bers to  recall  later.  Memory  for  recent  events  is  very 
defective,  especially  as  regards  the  temporal  arrangement. 
Fabrications  of  memory  frequently  appear. 

The  train  of  thought  is  mostly  coherent,  yet  the  patients 
show  considerable  distractibility.  The  goal  ideas  are  flighty 
and  not  very  well  fixed.  During  a  conversation  trifling  in- 
cidents or  hallucinations  may  hinder  the  thought  or  lead  it 
off  into  various  directions.  The  patients  experience  diffi- 
culty in  collecting  their  thoughts,  are  unable  to  recognize 
contradictions,  and  fail  in  trying  to  solve  problems  which 
require  thought. 

In  emotional  attitude  the  patients  are  anxious  and  fearful 
or  happy  and  cheerful,  depending  upon  the  character  of  the 
hallucinations  or  illusions.  They  may  change  rapidly  from 
intense  fear  to  jolly  laughter,  and  even  indulge  in  witty  re- 


DELIRIUM  TREMENS  179 

marks.  Thus  elation  and  the  fear  of  death  may  rapidly 
follow  each  other,  and  in  tins  way  there  may  develop  a 
mixture  of  concealed  anxiety  and  humor,  when  it  seems  as 
though  the  patients,  in  spite  of  the  dreadful  pictures  and 
fears,  still  recognize  more  or  less  clearly  the  humorous  im- 
possibilities and  contradictions  in  their  delirious  experi- 
ences. 

In  actions  the  patients  are  more  or  less  restless  and 
talkative.  They  are  seldom  able  to  engage  in  work,  though 
occasionally  a  patient  continues  at  his  occupation  until  the 
disease  is  well  established.  Usually  they  take  an  active  part 
in  their  numerous  hallucinations.  They  plug  the  ears  to 
keep  out  disagreeable  noises,  crawl  under  the  bed  to  elude 
persecutors,  escape  from  the  window  to  get  away  from  the 
sulphur  vapors  and  the  enemies  waiting  outside  the  door; 
they  answer  the  imaginary  voices,  run  to  the  station  for 
protection,  or  amuse  themselves  with  their  beautiful  sur- 
roundings and  join  in  the  happy  company  of  imaginary 
revellers.  Sometimes  they  are  assertive  and  aggressive,  de- 
manding attention  or  carrying  out  divine  commands.  When 
in  fear  they  sometimes  commit  assaults,  but  they  rarely 
attempt  suicide. 

Many  chronic  alcoholics  develop  what  in  their  own  parlance 
is  called  a  "  touch  of  the  horrors,"  which  in  reality  is  an  abor- 
tive form  of  delirium,  tremens.1  Some  of  these  cases  come  under 
the  care  of  the  family  physician,  but  the  majority  of  them 
go  without  medical  attendance.  The  symptoms  are  those  of 
the  prodromal  stage  of  delirium  tremens.  During  a  de- 
bauch or  following  abstinence  or  mental  shock,  there  develops 
some  paresthesia,  a  vague  f eeling  of  fear,  as  if  some  one  were 
constantly  behind  the  patients,  the  slightest  noise  causing 
them  to  be  startled.    While  in  this  state  they  have  isolated 

1  Berkley,  Mental  Diseases. 


180  FORMS  OF  MENTAL  DISEASE 

hallucinations  of  sight  and  hearing.  One  patient  saw  for  a 
moment  a  number  of  rats  scampering  across  the  floor,  others 
were  attracted  by  unnatural  voices.  It  very  frequently 
happens  at  night  that  some  object  appears  at  the  window 
for  a  second  and  is  gone.  The  patients  are  perfectly  con- 
scious, and  appreciate  their  condition.  Some  of  the  physical 
signs  of  delirium  tremens  are  usually  present.  The  condi- 
tion is  of  short  duration,  rarely  lasting  over  a  few  hours  or 
days. 

Physically.  —  Besides  the  various  sensory  disturbances, 
such  as  neuritic  disturbances,  paresthesias,  hyperesthesias, 
and  circumscribed  areas  of  anaesthesias  which  may  form  the 
basis  for  illusions  and  hallucinations,  there  is  sometimes  a 
lack  of  insensibility  which  will  permit  the  patients  to  sustain 
severe  injuries  without  complaint.  There  is  often  present 
great  muscular  weakness.  The  muscular  movements  tend 
to  be  coarse  and  unsteady,  and  the  gait  uncertain  and  stagger- 
ing. There  is  some  ataxia  and  pronounced  tremor  of  the 
tongue  and  fingers,  and  sometimes  of  the  extremities  and 
eyelids.  Speech  is  often  ataxic  and  paraphasic,  with  mal- 
position of  words  and  syllables,  and  in  the  severest  cases 
may  be  slurring  and  unintelligible.  Occasionally  in  the 
severe  cases  muscular  spasms  are  noticed.  Epileptiform 
seizures  are  frequent,  occurring  mostly  before  the  attack, 
in  ten  per  cent,  of  the  cases  one  to  two  days  before  the  out- 
break, less  often  during  the  attack,  and  sometimes  accom- 
panied by  transitory  paralytic  symptoms,  such  as  hemi- 
paresis.  The  tendon  reflexes  are  exaggerated.  Insomnia  is 
marked  from  the  first,  and  persists  unless  the  patients  be- 
come stuporous.  The  condition  of  nutrition  suffers,  because 
of  the  small  amount  of  nourishment  ingested,  which  is  due 
in  part  to  the  delusions  of  poisoning  and  in  part  to  the 
gastritis.    There  is  apt  to  be  a  slight  rise  of  temperature 


DELIRIUM  TREMENS  181 

during  the  first  few  days,  rarely  reaching  one  hundred  de- 
grees. The  pulse  rate  is  low  as  well  as  the  respiration, 
and  occasionally  there  is  profuse  perspiration. 

In  a  large  percentage  of  cases  the  urine  contains  albumen 
and  casts,  which  clears  up  with  the  psychosis.  Elsholz  finds 
in  the  blood  a  relative  leucocytosis,  with  a  diminution  of  the 
eosinophiles  at  the  height  of  the  psychosis. 

Course.  —  The  duration  of  the  delirium  varies  from  a  few 
days  to  two  weeks,  rarely  extending  beyond  three  weeks. 
The  improvement  comes  with  sleep.  The  hallucinations 
usually  fade  away  slowly,  though  sometimes  they  disappear 
within  a  night.  With  the  improvement  of  sleep  the  physical 
symptoms  disappear  gradually.  The  memory  of  the  events 
of  the  psychosis,  in  spite  of  great  clouding  of  conscious- 
ness, is  sometimes  surprisingly  clear,  though  it  later  tends  to 
fade. 

Not  all  cases  show  rapid  clearing  up  of  symptoms  with 
the  improvement  of  sleep.  A  few  suffer  a  second  attack 
after  a  few  days  or  even  a  week  of  clear  consciousness 
have  intervened,  and  in  spite  of  the  fact  that  they  have 
continued  abstinent.  Others  show  a  complete  alteration  in 
the  character  of  the  psychosis  after  the  hallucinations  and 
illusions  have  disappeared,  some  developing  the  character- 
istic polyneuritis  psychosis  or  the  alcoholic  hallucinatory 
dementia.  A  certain  number  of  cases  pass  into  alcoholic 
paranoia,  to  be  described  later. 

In  the  more  severe  cases  the  physical  signs  become  more 
prominent  and  there  develop  convulsions,  muscular  twitch- 
ing, ataxia,  and  disturbances  of  the  eye  muscles.  At  the 
same  time  the  insensibility  and  the  incoherence  increases, 
the  movements  become  weaker  and  the  pulse  smaller,  and 
finally  death  ensues,  with  sudden  loss  of  consciousness  or 
collapse. 


182  FORMS  OF  MENTAL  DISEASE 

Diagnosis.  —  The  diagnosis  of  the  disease  is  not  difficult 
if  previous  history  of  alcoholism  is  known.  Fever  delirium 
and  the  epileptic  befogged  states  may  be  confused  with 
delirium  tremens.  In  the  former  there  is  a  more  marked 
clouding  of  consciousness,  and,  especially  in  the  epileptic 
condition,  confused  delusions  of  a  religious  character  stand 
in  contrast  to  the  moderate  restlessness  without  impulsive- 
ness, the  active  hallucinations,  and  the  muscular  tremor  of 
the  alcoholic. 

The  delirium  of  dementia  paralytica  is  differentiated  from 
the  alcoholic  delirium  by  the  previous  history  of  change  of 
character,  evidences  of  failure  of  memory  and  judgment, 
paretic  physical  signs,  and  the  more  profound  clouding  of 
consciousness,  with  a  change  of  personality. 

Prognosis.  —  The  outcome  is  usually  favorable.  In  the 
unfavorable  cases  (three  to  nineteen  per  cent.)  pneumonia  is 
the  chief  cause  of  death  and  greatly  increases  the  fatality. 
Other  causes  of  death  are  cardiac  failure,  infection  follow- 
ing injury,  and  suicide. 

Treatment.  —  In  warding  off  the  development  of  delirium 
tremens  in  chronic  alcoholics  who  have  suffered  injury  or 
have  developed  pneumonia,  one  should  withdraw  the  alcohol 
at  once  and  attend  particularly  to  nutrition  and  sleepless- 
ness. Frequently  repeated  doses  of  ergot  or  the  administra- 
tion of  apomorphin  hypodermically  (see  p.  170)  aids  in  this 
respect.  The  first  indication  for  treatment  is  the  establish- 
ment of  proper  nutrition,  which  requires  frequently  repeated 
administration  of  small  quantities  of  liquid.  If  necessary, 
artificial  feeding  should  be  resorted  to.  Gastritis  with  nausea 
and  vomiting  may  necessitate  lavage.  The  second  indica- 
tion is  to  combat  insomnia,  for  which  purpose  a  combination 
of  3^  grains  each  of  chloral,  potassium,  and  sodium  bromide 
is  most  efficient,  repeated  every  hour  until  sleep  is  secured. 


DELIRIUM  TREMENS  183 

In  case  the  cardiac  condition  will  not  permit  the  use  of 
chloral,  paraldehyde  or  chloralmide  may  be  substituted. 
The  patient  should  be  confined  in  bed  and  watched  con- 
stantly. If  excitement  increases  to  such  an  extent  that  the 
patient  cannot  be  kept  in  bed,  then  the  prolonged  warm 
bath  must  be  employed  (see  p.  140).  Great  excitement  may 
necessitate  its  continuous  use,  combined  sometimes  with  the 
use  of  chloral  and  the  bromides  or  paraldehyde,  or  in  its 
extreme  cases,  the  use  of  hyoscine. 

As  already  indicated,  alcohol  should  always  be  withdrawn. 
In  case  the  slightest  evidence  of  cardiac  weakness  develops, 
one  should  not  hesitate  to  make  use  of  caffein,  camphor, 
or  camphorated  oil,  or  in  urgent  states  normal  saline 
infusion. 

Korssakow's  Psychosis 

In  1887  Korssakow  1  described  a  number  of  cases  of  ap- 
parent toxic  origin  and  associated  with  polyneuritic  symp- 
toms, which  were  characterized  particularly  by  a  profound 
disturbance  of  the  impressibility  of  memory,  disorientation,  and 
a  tendency  to  fabrications  of  memory.  Later  experience 
demonstrated  that  while  this  psychosis  occasionally  appeared 
in  connection  with  other  toxic  states  (see  p.  134),  it  developed 
most  often  on  the  basis  of  chronic  alcoholism.  It  also  be- 
came apparent  that  the  polyneuritic  symptoms  are  not  a 
constant  accompaniment  of  the  psychosis. 

Etiology.  —  The  intimate  relationship  of  this  psychosis  to 

korssakow,  Archiv  f.  Psychiatrie,  XXI,  669;  Allgem.  Zeitsch.  f. 
Psychiatrie,  XLVI,  475;  Tiling,  ebenda,  XLVIII,  549;  Uber  alkoholische 
Paralyse  und  infektioese  Neuritis  multiplex,  1897 ;  Jolly,  Charit6annalen, 
XXII;  Moenkemoeller,  Allgem.  Zeitschrift  f.  Psychiatrie,  LIV,  806; 
Raimann,  Wiener  klin.  Wochenschrift,  1900,  2 ;  Elsholz,  ebenda,  1900, 
15;  Heilbronner,  Monatsschrift  f.  Psychiatrie,  III,  459. 


184  FORMS  OF  MENTAL  DISEASE 

alcoholism  has  already  been  pointed  out.  Jolly  regards  it 
as  a  severe  form  of  delirium  tremens,  while  Bonhoeffer  de- 
scribes it  as  a  chronic  alcoholic  delirium.  It  develops  in 
three  per  cent,  of  the  cases  of  delirium  tremens.  It  is 
much  more  apt  (eleven  per  cent.)  to  occur  during  the  second 
or  subsequent  attacks  of  delirium  tremens.  Women 
appear  to  suffer  in  a  proportionately  larger  percentage  than 

men. 

Pathological  Anatomy.  —  There  is  an  extensive  destructive 
process  involving  the  nervous  tissue  from  the  cortex  to  the 
peripheral  nerves.    The  nerve  cells  present  the  usual  signs 
of  an  acute  process  while  the  nerve  fibres  give  evidence  of 
varying  degrees  of  destruction,  especially  in  the  region  of  the 
central  convolutions,  when  there  is  a  prolonged  course  of 
the  disease.     In  the  spinal  cord  there  is  an  extensive  atrophy 
of  the  fibres,  particularly  in  the  columns  of  Goll.     Of  par- 
ticular importance  are  the  numerous  small  hemorrhages,  oc- 
curring especially  in  the  central  gray  matter,  where  they  are 
regarded  as  the  cause  of   the  oculomotor  paralyses.    The 
acute  hemorrhagic  porencephalitis  superior,  described  by 
Wernicke,  according  to  Elsholz  and  Bonhoeffer,  is  frequently 
associated  with  Korssakow's  psychosis.    The  above  ana- 
tomical lesions,  which  are  indicative  of  an  extensive  destruc- 
tion of  nerve  tissue,  in  reality  are  only  what  one  would 
expect  to  find  in  severe  alcoholic  intoxication. 

Symptomatology.  —  The  symptoms  at  the  onset  are  similar 
to  those  of  delirium  tremens.  But  after  the  usual  course  of 
the  delirium  symptoms,  disorientation  continues,  while  the 
hallucinations,  restlessness,  and  insomnia  disappear.  The 
delirious  experiences  are  not  corrected,  and  in  addition  there 
develops  a  very  striking  disturbance  of  impressibility  of 
memory  (Merkfahigkeit).  The  symptoms  sometimes  follow 
a  rapidly  developing  stupor  with  hallucinations,  and  they 


KORSSAKOW'S  PSYCHOSIS  185 

still  more  rarely  develop  gradually  from  the  chronic  alco- 
holic state. 

In  severe  cases  this  disturbance  of  memory  is  so  pro- 
nounced that  the  patients  cannot  remember  for  a  few  min- 
utes or  even  seconds  that  which  they  have  just  experienced. 
They  are  conscious  and  understand  what  is  said  to  them, 
yet  they  are  wholly  unable  to  put  together  their  recent  ex- 
periences or  to  form  any  picture  of  the  course  of  events  in 
their  lives.  They  do  not  know  what  has  happened  in  the 
past  hour,  although  in  the  meantime  they  have  washed  and 
prepared  for  and  eaten  dinner  and  been  visited  by  the 
physician,  and,  indeed,  even  if  told  all  this,  they  cannot  fit 
it  into  their  memory  and  correct  the  defect.  A  few  very 
striking  impressions  may  be  retained,  but  they  are  never 
connected  with  the  events  immediately  preceding  or  follow- 
ing. The  first  result  of  this  disturbance  of  memory  is  a 
complete  loss  of  orientation.  The  patients  have  no  concep- 
tion of  the  time.  They  cannot  tell  where  they  are  or  those 
about  them,  and  usually  greet  the  physician  as  an  old  ac- 
quaintance, though  they  cannot  recall  the  name. 

While  the  memory  is  more  particularly  affected  for  events 
since  the  onset  of  the  psychosis,  yet  it  sometimes  happens 
that  there  is  a  distinct  loss  of  memory  for  events  extending 
back  several  months  or  even  years.  They  cannot  tell  you 
how  they  have  been  employed,  or  where  they  have  been,  or 
have  lived  during  all  this  time.  Some  forget  that  they  are 
married  or  have  children.  A  few  striking  incidents  may  be  re- 
called, but  the  time  of  their  occurrence  cannot  be  established. 
The  lapses  in  memory  are  not  only  not  recognized  by  the 
patient,  but  are  very  apt  to  be  filled  in  with  falsifications  of 
memory,  which  are  related  by  the  patient  with  a  feeling  of 
absolute  certainty.  These  falsifications  may  apply  only  to 
the  lapses  of  recent  date.    The  patients  then  relate  visits 


186  FORMS  OF  MENTAL  DISEASE 

which  they  have  just  had,  or  journeys  which  they  have  made, 
and  give  a  detailed  account  of  the  good  times  they  have  had, 
while  in  reality  for  months  they  have  been  leading  a  wholly 
uninteresting  and  monotonous  existence.  These  fabrica- 
tions can  usually  be  drawn  out  by  questioning  and  influenced 
by  suggestions.  The  fabrications  are  not  always  limited 
to  mere  filling  the  lapses  of  memory  with  ordinary  experiences, 
but  the  patient  may  strive  to  amplify  the  incidents  with  alto- 
gether new  and  fictitious  events.  This  latter  tendency  is 
pronounced  only  during  the  earlier  stages  of  the  disease. 
Indeed,  the  fabrication  may  extend  to  an  intricate  and 
fantastic  falsification  of  the  last  ten  years  of  the  patients' 
lives,  concerning  which  they  relate  all  kinds  of  wonderful 
experiences.  The  apparent  accuracy  of  these  fabrications 
forcibly  impresses  one,  together  with  the  wealth  of  detail  and 
the  absolute  certainty  which  they  possess  for  the  patient  at 
the  time.  Although  the  facts  are  frequently  altered,  each 
time  they  are  related  as  clearly  and  assuredly  as  if  they  had 
occurred  only  yesterday.  Occasionally,  expansive  and  de- 
pressive delusions  are  added,  but  these  also  tend  to  change 
rapidly  and  as  suddenly  appear  and  disappear.  Some- 
times hallucinations  also  occur  at  the  beginning,  which  later 
disappear. 

The  function  of  the  intellect  outside  of  the  disorders 
already  mentioned  is  not  particularly  impaired.  The 
patients  show  good  judgment  on  other  matters,  understand 
facts  presented  to  them,  answer  questions  to  the  point, 
and  know  how  to  cleverly  conceal  the  lapses  in  their  memory. 
On  the  other  hand,  they  do  not  possess  a  clear  insight  into 
their  condition  and  are  unable  to  employ  themselves  profit- 
ably. They  can  write  letters  well  and  carry  out  orders, 
but  they  become  shiftless  and  lead  a  thoughtless  and  in- 
active life. 


KORSSAKOW'S  PSYCHOSIS  187 

The  emotional  attitude  at  the  onset  is  mostly  anxious,  but 
later  it  becomes  one  of  indifference  and  apathy,  though 
sometimes  there  is  distrust  and  irritability,  while  in  other 
cases  a  certain  degree  of  good  humor  or  elation  exists. 
Usually  the  emotional  attitude  is  also  easily  changed  by 
suggestion  into  one  state  or  another. 

The  conduct  and  actions  of  the  patients  after  the  subsidence 
of  the  delirium  become  orderly.  The  patients  may  com- 
plain a  little  about  their  surroundings,  but  they  are  mostly 
quiet.  As  a  result  of  faulty  memory  they  are  always 
neglecting  to  attend  to  personal  duties,  or  repeating  what 
they  have  already  done;  hence  the  same  questions  are  fre- 
quently asked,  and  numerous  letters  are  rewritten.  Delu- 
sions, if  present,  do  not  greatly  influence  the  conduct. 

The  physical  symptoms  are  usually  those  of  alcoholic 
neuritis.  These,  however,  may  be  absent.  The  extent  of 
the  symptoms  also  may  vary  considerably,  but  usually  they 
are  confined  to  minor  paralytic  signs,  atony  and  reduced 
volume  of  certain  muscle  groups,  especially  in  the  legs; 
Romberg  signs;  sensitiveness  of  the  nerves  and  muscles  to 
pressure;  more  or  less  extensive  anaesthesia,  paresthesia,  or 
hyperesthesia;  loss,  seldom  increase,  of  the  tendon  reflexes; 
cystic  disorders,  some  degree  of  ataxia;  difficulties  of 
deglutition  and  speech;  and  paresis  of  the  facial  nerve 
and  especially  paralysis  of  the  eye  muscles  (abducens).  The 
pupils  are  often  unequal,  and  notched,  and  sometimes  do  not 
react  to  light.  There  is  also  tremor  of  the  fingers,  and  fre- 
quently a  history  of  epileptiform  attacks.  Furthermore, 
symptoms  indicative  of  chronic  alcoholism  may  be  present, 
as  nephritis,  hypertrophy,  or  atrophy  of  the  fiver,  icterus, 
ascites,  and  edema;  also  faulty  nutrition,  anorexia,  and  some- 
times nausea. 

Course.  —  Following  the  rapid  development  of  the  disease, 


188  FORMS  OF  MENTAL  DISEASE 

the  course  is  usually  a  long  one.  In  some  cases  death  en- 
sues from  paralysis  of  the  heart  or  respiration.  Not  infre- 
quently a  rapidly  developing  tuberculosis  leads  to  death. 
After  a  period  of  several  months,  there  may  be  gradual 
improvement,  with  disappearance  of  the  neuritic  symptoms, 
a  return  of  orientation  and  improvement  of  memory.  In  a 
small  number  of  cases  the  improvement  may,  in  the  course 
of  five  to  nine  months,  be  sufficient  to  permit  the  patient's 
returning  home,  yet  there  regularly  remains  a  considerable 
increased  susceptibility  to  fatigue,  uncertainty  of  memory, 
emotional  apathy  or  irritability,  weakness  of  will,  and  limited 
activity.  Further  indulgence  in  alcohol  tends  to  quickly  in- 
tensify these  residual  symptoms.  Usually  the  disease  ter- 
minates in  a  permanent  dementia,  which  is  particularly 
characterized  by  the  persistence  of  falsifications  of  memory. 

Diagnosis.  —  The  conditions  of  excitement  at  the  onset  of 
the  post  infection  psychoses  may  be  differentiated  by  the  fact 
that  clouding  of  consciousness  is  much  more  pronounced, 
and  hallucinations  and  illusions  are  more  in  the  background; 
further,  the  alcoholic  tremor  is  absent,  the  emotional  attitude 
does  not  present  the  alcoholic  characteristics,  and  finally  the 
prognosis  is  distinctly  more  favorable.  Paresis  is  distin- 
guished by  the  usual  history  of  a  gradual  onset.  Pronounced 
neuritic  symptoms  with  paralysis  of  the  eye  muscles  and  the 
alcoholic  tremors  speak  for  Korssakow's  psychosis,  while 
indications  of  aphasia,  hesitating  speech,  marked  para- 
graphia, and  cerebral  paralysis  point  to  paresis.  Again,  the 
stupid  or  humorous  emotional  attitude  of  the  alcoholic  con- 
trasts with  the  silly  happiness  of  the  paretic,  while  the  only 
intellectual  disturbance  of  Korssakow's  psychosis  is  seen  in 
the  memory,  which  may  not  involve  the  more  remote  events 
of  life,  as  in  paresis.  Presbyophrenia  also  is  characterized 
by  impaired  impressibility  of  memory,  loss  of  orientation 


ACUTE  ALCOHOLIC  HALLUCINOSIS  189 

and  fabrication ;  but  this  disease  occurs  mostly  in  the  senile 
period,  may  not  be  preceded  by  an  alcoholic  history,  and  is 
not  accompanied  by  neuritic  disturbances.  Again,  the 
activity  of  the  patients  is  greater;  they  are  communicative, 
often  garrulous,  trouble  themselves  about  the  environment, 
display  a  childish  emotional  state  and  a  certain  busyness, 
especially  at  night.  The  diagnosis  may  be  difficult  if  the 
presbyophrenic  patient  has  been  addicted  to  excessive 
alcoholism. 

Treatment.  —  During  the  early  stages  of  the  disease 
the  treatment  is  identical  with  that  in  delirium  tremens 
(see  p.  182).  The  alcohol  must  be  absolutely  withdrawn, 
and  the  patient  placed  either  in  an  institution  or  in  a 
particularly  satisfactory  family  environment,  because  of  the 
great  weakness  of  will  displayed  by  the  patients.  Later  in 
the  course  of  the  disease,  it  may-  be  necessary  to  employ 
electricity,  massage,  and  gymnastic  movements  in  order  to 
combat  the  muscular  atrophy  accompanying  the  neuritis. 
Some  improvement  of  the  memory  disturbance  may  result 
from  systematic  mental  exercises. 

Acute  Alcoholic  Hallucinosis 

This  psychosis1  is  characterized  by  the  sudden  develop- 
ment of  coherent  delusions  of  persecution,  based  mostly  upon 
hallucinations  of  hearing,  with  barely  any  clouding  of  con- 
sciousness. 

Etiology.  —  The  etiology  of  acute  alcoholic  hallucinosis  is 
identical  to  that  in  delirium  tremens  (see  p.  172).  Why  one 
case  should  develop  into  delirium  tremens  and  another  into 
acute  alcoholic  hallucinosis  is  yet  unknown.  The  various 
explanations  offered  for  this  by  Bonhoeffer  and  others  are 

1  Mitchell,  Types  of  Alcoholic  Insanity.  Amer.  Jour,  of  Ins.  Oct.  1904, 
p.  251. 


190  FORMS  OF  MENTAL  DISEASE 

not  satisfactory.  Acute  alcoholic  hallucinosis  represents,  in 
America,  forty-five  per  cent,  of  the  cases  of  alcoholic  insanity 
committed  to  institutions,  and  occurs  mostly  in  men  of  middle 
life,  many  of  whom  have  been  habitual  daily  drinkers  for 
years. 

Symptomatology.  —  Occasionally,  there  are  a  few  prodro- 
mal systoms,  such  as  indisposition,  headache,  dizziness, 
insomnia,  and  irritability.  The  onset  is  usually  sudden. 
The  patients  at  first  are  disturbed  during  the  evening  or  at 
night  by  indefinite  noises,  like  shouting  voices,  cryings,  and 
ringing  bells.  These  hallucinations  soon  become  more 
definite  when  they  hear  their  own  names  called  and  numer- 
ous epithets.  The  patients  then  hear  remarks  about  them- 
selves, which  appear  to  come  from  the  next  room  or  from 
fellow-workmen.  These  remarks  are  usually  quite  clear, 
and  occasionally  are  heard  in  only  one  ear.  The  voices  are 
recognized  as  those  of  an  acquaintance,  a  chum,  or  a  fellow- 
workman,  but  rarely  as  those  of  the  immediate  family,  and 
consist  of  imprecations  and  references  to  misdeeds  of  their 
past  lives.  They  hear  themselves  called  murderers,  liars, 
and  thieves.  They  learn  that  they  are  to  be  electrocuted, 
that  the  wife  is  unfaithful,  or  that  the  children  have  been 
drowned.  They  are  laughed  at  because  of  their  anxiety. 
At  times  they  overhear  long  discussions  concerning  their 
welfare,  in  which  various  events  of  their  past  lives  are  re- 
hearsed or  an  indictment  for  murder  is  read  against  them. 
Again,  a  group  of  men  under  their  window  discuss  means  of 
capturing  them  and  bringing  them  to  a  public  place  for  the 
purpose  of  having  them  lynched.  All  this  is  so  very  real  to 
the  patients  that  it  is  impossible  to  convince  them  to  the 
contrary.  Furthermore,  it  almost  always  happens  that  the 
voices  are  not  spoken  directly  at  them,  but  they  only  over- 
hear what  is  being  said  among  others  about  them.    The 


ACUTE  ALCOHOLIC   HALLUCINOSIS  191 

content  of  these  hallucinations  is  always  of  a  depreciatory 
nature.  Besides  these  numerous  hallucinations  of  hearing, 
there  are  a  few  hallucinations  of  sight,  especially  at  night. 
Strange  and  threatening  forms  appear  before  them,  some 
crawling  from  under  the  bed,  others  creeping  on  the  wall; 
brilliant  specks  come  across  the  field  of  vision,  and  they  may 
even  see  double.  At  times  the  food  has  a  peculiar  taste, 
and  excites  suspicion. 

In  connection  with  these  various  hallucinations  there 
regularly  develop  pronounced  delusions,  mostly  of  a  depres- 
sive nature.  The  patients  believe  that  they  are  the  center 
of  attraction;  every  one  about  them  watches  and  threatens 
them.  Their  every  thought  and  action  is  known  and  com- 
mented upon.  Passers  on  the  street  jeer  at  them,  fellow- 
passengers  on  the  trolley  watch  them  closely,  visitors  in  the 
factory  are  told  all  about  them  and  stand  and  gaze  at  them, 
enemies  shoot  through  the  fence  at  them,  and  detectives 
in  citizen's  clothes  follow  them  wherever  they  go.  They  are 
distrustful  of  their  surroundings,  are  constantly  on  the  alert 
for  impending  arrest,  or  they  go  into  hiding,  and  refuse  to 
leave  their  homes.  These  patients  argue  that  they  are  con- 
demned to  die,  and  show  considerable  emotion.  Fellow- 
patients  refuse  to  speak  to  them  because  they  are  implicated 
in  the  seduction  of  their  wives.  Sometimes  they  refuse  to 
answer  questions  or  associate  with  any  one  until  brought  to 
the  court  room  for  the  supposed  trial.  At  times  they  find 
consolation  in  prayer  and  in  reading  the  Bible.  These 
various  delusions  usually  remain  within  the  realm  of  possi- 
bility, and  appear  more  like  attempts  on  the  part  of  the 
patient  to  explain  the  hallucinations.  Occasionally,  how- 
ever, the  delusions  are  of  a  fantastic  nature  and  simulate 
those  occurring  in  delirium  tremens,  sometimes  also  being 
associated  with  expansive  delusions. 


192  FORMS  OF  MENTAL  DISEASE 

The  cojisciousness  is  barely  disturbed,  there  being  only  a 
slight  dazedness.  Yet  at  night,  and  at  the  onset,  there 
may  be  a  slight  transit oiy  delirium.  The  patients  are  mostly 
oriented,  their  speech  coherent,  and  they  are  able  to  make 
an  accurate  statement  of  their  symptoms,  except  occasionally 
in  giving  the  correct  time  of  their  occurrence.  They  rarely 
possess  clear  insight,  but  they  often  realize  that  they  are 
different,  and  frequently  accuse  their  persecutors  of  drugging 
them  or  making  them  crazy.  Others  claim  that  they  are 
only  "  nervous." 

The  emotional  attitude  at  the  onset  is  usually  that  of 
anxiety,  but  later  in  the  course  of  the  disease  there  is  that 
characteristic  mixture  of  anxiety  and  cheerfulness  seen  in 
delirium  tremens,  when  the  patients  relate  their  frightful 
experiences  with  indifference,  or  perhaps  laugh  at  the  ab- 
surdity of  their  attracting  so  much  attention.  When  not 
in  fear,  they  are  quiet,  reserved,  and  in  replying  to  questions 
are  monosyllabic. 

In  conduct  the  patients  may  remain  quite  orderly,  and  not 
infrequently  continue  at  work  for  days  and  even  weeks. 
But  even  during  this  period  peculiarities  of  manner  develop 
as  the  result  of  their  delusions.  They  become  reserved, 
silent,  and  avoid  acquaintances;  later  they  often  apply  to  the 
police  for  protection  or  hide  under  the  bed,  and  some  even 
attempt  suicide.  In  our  experience  these  patients  are  some- 
times the  most  dangerous  of  the  insane.  They  take  the  law 
into  their  own  hands,  purchase  firearms,  and  assault  those 
maligning  their  character  or  planning  their  destruction. 

Physically.  —  The  sleep  is  regularly  disturbed.  The 
appetite  fails  and  there  is  a  loss  of  weight.  The  reflexes  are 
occasionally  exaggerated,  and  tremor  of  the  tongue  and  hands 
is  often  present,  though  not  always.  Occasionally,  there  are 
neuritic  symptoms. 


ACUTE  ALCOHOLIC  HALLUCINOSIS  193 

Course.  —  The  course  of  the  psychosis  may  be  either  acute 
or  subacute.  When  acute,  the  duration  varies  from  two  to 
three  weeks,  with  rapid  disappearance  of  the  symptoms, 
sometimes  during  a  night.  The  prospect  for  a  short  course 
seems  better  the  nearer  the  symptoms  approach  those  of 
delirium  tremens.  Occasionally,  abortive  forms  of  acute 
alcoholic  hallucinosis  are  observed,  in  which  the  patients  for 
a  few  hours  or  a  couple  of  days  suddenly  develop  isolated 
transitory  hallucinations,  with  anxiety,  and  a  few  persecutory 
delusions,  such  as,  that  they  are  to  be  poisoned,  assaulted 
by  fellow-workmen,  or  are  watched  by  the  police.  In  the 
subacute  form  the  symptoms  may  persist  from  one  to  eight 
months,  with  numerous  fluctuations,  and  then  disappear 
gradually.  The  memory  for  events  of  the  psychosis  is 
usually  excellent. 

Diagnosis.  —  The  differentiation  between  delirium  tremens 
and  acute  alcoholic  hallucinosis  is  by  no  means  sharply  de- 
fined. There  are  cases  of  the  latter  in  which  the  orientation 
is  markedly  disturbed  for  only  a  short  time,  hallucinations 
of  hearing  are  very  pronounced,  and  there  seems  to  be  a 
definite  delusional  connection  between  the  various  individual 
morbid  experiences,  while,  on  the  other  hand,  the  difficulty 
of  apprehension,  the  disturbance  of  the  impressibility  of 
memory,  the  presence  of  visual  and  tactile  hallucinations, 
suggestibility,  restlessness,  and  tremor  give  the  stamp  of 
delirium  tremens.  Provided  they  are  not  simply  cases  of 
undeveloped  delirium  tremens,  may  they  not  possibly  repre- 
sent a  combination  of  delirium  tremens  and  acute  alcoholic 
hallucinosis,  similar  to  those  cases  of  delirium  tremens  occa- 
sionally seen  in  epileptics,  paretics,  hebephrenics,  and  manics  ? 
But  usually  the  retention  of  a  good  orientation,  the  absence 
of  restlessness  and  striking  physical  signs,  the  predominance 
of  hallucinations  of  hearing  with  coherent  delusions  based 


194  FORMS  OF   MENTAL  DISEASE 

upon  them,  and  a  more  prolonged  course  are  sufficiently 
distinctive  evidences  of  acute  alcoholic  hallucinosis. 

The  differentiation  from  dementia  prcecox,  particularly 
the  paranoid  form,  may  be  difficult,  but  in  dementia  prsecox 
the  onset  is  far  more  gradual:  there  is  stupidity;  looseness 
of  thought;  a  lack  of  energy  for  work;  peculiar  conduct, 
such  as,  staring,  impulsive  acts,  and  catatonic  signs.  The 
hallucinations  in  dementia  prsecox  are  directed  to  the 
patient,  while  in  the  alcoholic  psychosis  the  patient  simply 
overhears  what  is  said.  The  delusions  involve  mostly  the 
physical  and  mental  personality,  which  in  the  alcoholic 
psychosis  are  not  involved.  Finally,  the  emotional  attitude 
is  superficial,  while  in  the  acute  alcoholic  hallucinosis  the 
anxiety  is  genuine  and  often  desperate,  except  for  the  occa- 
sional appearance  of  the  alcoholic  humor.  Paresis  may  be 
differentiated  by  the  same  signs  in  addition  to  the  presence 
of  paretic  physical  signs  and  weakness  of  memory  and  judg- 
ment. Some  cases  of  manic-depressive  insanity  may  present 
some  similarities  to  acute  alcoholic  hallucinosis,  but  they 
can  be  successfully  differentiated  by  the  previous  history 
of  the  case,  and  by  tendency  to  delusions  of  self-accusations, 
which  are  absent  in  the  alcoholic  condition. 

Prognosis.  —  The  outcome  is  usually  favorable,  as  a  large 
proportion  of  the  acute  cases  recover.  There  is  great  danger 
of  relapse  with  continued  drinking,  and  subsequent  attacks 
are  more  prolonged.  Some  patients  have  four  or  five  attacks. 
The  outlook  in  the  subacute  cases  is  not  as  favorable,  as  less 
than  twenty-five  per  cent,  wholly  recover.  In  some  cases 
there  finally  develops  a  condition  of  permanent  dementia, 
with  hallucinations  and  delusions. 

Treatment.  —  The  chief  indications  are  the  absolute  with- 
drawal of  alcohol,  the  administration  of  a  nutritious  diet, 
and  incessant  watching  to  prevent  injury  to  self  and  others. 


ALCOHOLIC  HALLUCINATORY  DEMENTIA  195 

The  course  of  the  disease  may  sometimes  be  cut  short  at  the 
onset  by  the  use  of  hypnotics  to  overcome  the  insomnia  and 
of  the  prolonged  warm  bath  to  ameliorate  the  anxiety. 

Alcoholic  Hallucinatory   Dementia 

This  type  of  alcoholic  psychosis,  provisionally  called  alco- 
holic hallucinatory  dementia  (or  alcoholic  paranoia1),  is 
characterized  by  the  sudden  development  of  numerous  hal- 
lucinations, many  depreciatory  delusions  of  reference,  in- 
fluence and  persecution,  associated  somatic  delusions,  and 
occasional  change  of  personality,  with  some  emotional  anxiety 
and  irritability,  usually  leading  after  a  long  course  to  moderate 
dementia.  It  frequently  represents  the  end  stage  of  the 
acute  alcoholic  hallucinosis  and  as  often  follows  delirium 
tremens. 

Symptomatology.  —  The  onset  is  sudden.  If  acute  al- 
coholic hallucinosis  or  delirium  tremens  have  preceded, 
the  patients  having  become  oriented  and  quiet,  and  having 
corrected  at  least  a  part  of  their  delirious  experiences,  con- 
tinue somewhat  constrained  and  suspicious.  Then  hallu- 
cinations, particularly  of  hearing,  develop  again,  and  the 
patients  complain  of  hearing  threatening  voices,  that  others 
are  reading  their  thoughts,  and  that  they  are  being  influenced 
in  various  ways.  They  feel  that  they  are  being  hypnotized, 
electrified,  or  chloroformed,  are  experimented  upon  when 
asleep;  think  that  men  are  breathing  on  them,  smearing 
mucus  over  them,  changing  their  clothing,  and  creating  dis- 
gusting odors  about  them.  Comments  are  printed  in  the 
daily  papers  about  themselves,  and  actors  make  allusions 
to  them  from  the  stage.  Very  often  their  delusions  have  a 
sexual  content,  when  they  claim  that  they  have  been  as- 
saulted, have  their  semen  drawn  off  nightly,  and  that  their 
1  Luther,  Allgem.  Zeitsch:   fur  Psychiatrie,  LIX,  20,  1902. 


196  FORMS  OF  MENTAL  DISEASE 

organs  are  being  shrunken  up.  These  delusions  are  usually 
not  elaborated,  but  remain  unchanged  from  week  to  week, 
and  are  almost  always  expressed  in  the  same  phraseology. 
Witches  and  spirits  are  everywhere,  assuming  various  forms, 
and  constantly  offering  threats;  everything  is  poisoned,  and 
they  cannot  escape  the  hypnotic  influence.  Occasionally, 
the  delusions  are  still  more  fantastic  and  quite  changeable. 
Expansive  delusions  may  appear,  but  they  also  are  limited 
in  content,  although  they  are  fantastic.  The  patients'  judg- 
ment concerning  the  surroundings,  except  in  the  severer 
cases,  is  quite  good;  they  exhibit  activity,  converse  with 
their  associates,  follow  a  daily  routine,  show  a  tendency  to 
employ  themselves,  and  are  quite  natural,  in  as  far  as  their 
delusions  are  not  involved.  The  memory  shows  no  striking 
disturbances.  Nevertheless,  one  can  detect  a  considerable 
degree  of  mental  weakness. 

The  emotional  attitude  at  the  onset  is  one  of  anxiety  or 
irritability,  impelling  the  patients  at  times  to  attempt 
suicide  or  attack  their  persecutors.  Later,  there  regularly 
develops  a  more  or  less  humorous  attitude,  manifested  in 
witty  and  facetious  remarks  and  rendering  the  suspicious 
and  excitable  patients  more  pliable  and  approachable. 
Physically,  besides  the  alcoholic  tremor,  there  are  often 
present  more  or  less  severe  neuritic  disturbances. 

Course.  —  The  course  of  this  disease,  unless  abstinence  is 
enforced,  is  progressive.  With  persistent  abstinence,  the 
hallucinations  and  delusions  slowly  subside.  In  some  cases 
they  may  entirely  vanish,  leaving  the  patient  in  a  condition 
of  simple  alcoholic  dementia.  But  usually  they  persist  for 
many  years,  though  steadily  becoming  weaker.  Numer- 
ous fluctuations  of  the  symptoms  are  characteristic;  at  times 
the  patients  express  some  insight  into  their  condition;  they 
think  that  they  are  sick,  but  they  have  no  idea  of  how  they 


ALCOHOLIC  PARANOIA  197 

came  into  such  a  state,  and  they  are  able  also  to  associate 
in  a  friendly  manner  with  their  supposed  persecutors;  at 
other  times  they  become  excitable  without  apparent  cause, 
complain  of  threatening  hallucinations,  and  also  become 
aggressive,  but  they  are  usually  quieted  without  difficulty. 

Diagnosis.  —  Alcoholic  hallucinatory  dementia  may  be 
distinguished  from  some  of  the  end  stages  of  dementia  prcecox 
by  the  history  of  the  development  of  the  disease,  by  the  fact 
that  the  patients  possess  a  greater  emotional  and  intellectual 
activity,  are  more  natural  and  approachable  in  conduct,  and 
show  the  characteristic  alcoholic  humor.  Furthermore,  the 
symptoms  do  not  progress  if  total  abstinence  is  maintained, 
but  rather  tend  to  subside.  There  is,  occasionally,  a  case  of 
severe  alcoholism,  with  pronounced  catatonic  symptoms. 
In  such  cases  it  would  seem  justifiable  to  assume  that  there 
is  a  combination  of  both  diseases. 

Alcoholic  Paranoia 

This  form  of  alcoholic  insanity  comprises  a  small  group  of 
chronic  alcoholics  who  gradually  develop  a  delusional  state 
characterized  particularly  by  delusions  of  jealousy. 

Symptomatology.  —  The  family  discord  that  naturally 
follows  excessive  drinking,  together  with  the  wife's  aversion 
to  sexual  intercourse,  and  the  increasing  impotency  of  the 
alcoholic,  is  the  nucleus  about  which  the  delusions  of 
jealousy  form.  The  tendency  displayed  by  the  alcoholic  to 
lay  the  blame  for  everything  upon  some  one  else,  naturally 
engenders  the  idea  that  the  wife  is  unfaithful,  and  that  the 
real  cause  of  these  difficulties  lies  in  the  fondness  of  the 
wife  for  other  men  or  of  the  men  for  other  women.  Insig- 
nificant occurrences  are  regarded  as  important  evidence  of 
this  infidelity:  the  assistance  of  some  one  in  carrying  a 
bundle,  the  fondness  of  a  friend  for  their  children,  the 


198  FORMS  OF  MENTAL  DISEASE 

voluntary  implication  of  a  neighbor  in  a  family  quarrel. 
The  frequent  clanging  of  a  car  bell  means  that  the  motor- 
man  is  a  correspondent.  A  side  glance  from  a  passer  on  the 
street,  the  arrival  of  an  unusual  letter,  and  even  association 
with  another  man's  wife  are  held  as  sufficient  proof  of  the 
suspected  misbehavior.  Furthermore,  the  home  and  chil- 
dren are  neglected.  Patients  have  seen  the  wife  enter  the 
apartments  of  a  neighbor,  and  from  noises  which  they  have 
heard  are  sure  that  she  was  guilty  of  adultery.  Frequently, 
the  children  are  disclaimed  as  those  of  other  men,  and  hence 
must  share  in  the  abuse.  Sufficient  evidence  of  this  is  found 
in  the  fact  that  they  have  different  colored  hair  or  different 
dispositions.  The  saloon  keeper  is  implicated,  if  he  refuses 
to  give  them  credit  for  liquor,  or  the  coachman,  if  he  hap- 
pens to  be  amiss  in  any  of  his  duties.  Associated  with 
these  delusions  of  infidelity  there  may  be  delusions  of  poi- 
soning. 

These  delusions  of  jealousy  are  by  no  means  confined  to 
married  persons,  but  also  exist  in  the  unmarried  when  those 
persons  with  whom  they  are  most  intimately  associated,  the 
mother,  sister,  the  paramour,  and  sometimes  the  clergy 
become  the  objects  of  their  jealousy  and  assaults.  These 
delusions  are  not  elaborated  and  usually  remain  within 
the  realm  of  possibility.  The  patients,  however,  state  them 
coherently,  oftentimes  displaying  considerable  emotion,  and, 
indeed,  in  this  way  they  frequently  convince  chance  ac- 
quaintances of  the  great  injustice  done.  There  are  occa- 
sional hallucinations  of  hearing,  when  the  patients  hear 
peculiar  noises  about  the  house,  such  as  a  creaking  of  the 
door,  whispering,  rattling  of  the  shutters,  or  suspicious 
sounds  in  another  room.  There  may  be  a  peculiar  odor  in 
the  house,  or  an  odd  taste  in  the  food,  which  is  offered  as 
proof  that  an  effort  is  being  made  to  poison  them.    This 


ALCOHOLIC  PARANOIA  199 

incites  them  to  nail  down  the  windows  and  to  fasten  the 
door  in  order  to  keep  out  the  lovers. 

There  is  no  clouding  of  consciousness.  In  actions,  the 
patients  usually  exhibit  marked  weakness;  they  bemoan 
their  misfortunes  while  submitting  to  the  injustice.  At 
times  the  actions  are  entirely  out  of  accord  with  their  delu- 
sions, and  this  is  especially  true  in  cases  of  long  duration. 
A  man  may  live  peaceably  with  his  wife,  whom  he  accuses  of 
committing  adultery  night  after  night.  Sometimes  they  are 
very  irritable,  and  in  fits  of  anger  may  be  both  aggressive 
and  destructive.  When  under  the  influence  of  alcohol,  the 
conduct  of  the  patients  is  apt  to  be  wholly  changed;  then 
they  become  aggressive  and  threatening  and,  not  infrequently, 
make  murderous  assaults  upon  their  wives  or  the  objects  of 
their  jealousy. 

Course.  —  The  course  of  the  disease  is  usually  progressive. 
The  delusions  seldom  disappear  permanently,  though  absti- 
nence from  alcohol  often  brings  improvement,  especially  in 
conjunction  with  confinement  in  an  institution.  When  re- 
moved from  home  environment,  the  delusions  subside  and 
patients  are  able  to  live  very  comfortably.  In  some  patients 
the  delusions  subside  and  are  denied;  they  desire  to  "  let 
bygones  be  bygones  ";  "  everything  is  past,"  and  allow  the 
inference  that  they  have  been  mistaken.  This  apparent 
improvement,  oftentimes  accompanied  by  an  alleged  in- 
sight, influences  one  to  yield  to  their  importunities  for  re- 
lease; but  regularly  the  return  to  home  surroundings,  with 
an  opportunity  to  secure  alcohol,  soon  leads  to  recurrence 
of  delusions. 

Diagnosis.  —  It  is  often  difficult  to  distinguish  the  delu- 
sions of  infidelity  expressed  by  the  patient  from  actual 
occurrences  and  facts.  The  conduct  of  the  alcoholic  fre- 
quently results  in  an  actual  and  permanent  estrangement  of 


200  FORMS  OF  MENTAL  DISEASE 

the  man  and  wife,  which  naturally  smooths  the  way  for 
adultery.  One  must  rely  in  his  judgment  upon  the  grounds 
for  jealousy  offered  by  the  patient.  The  positiveness  with 
which  the  patient  draws  his  conclusions  from  insignificant 
data,  and  the  conviction  with  which  he  applies  these  to 
others,  and  finally  the  occasional  relation  of  strange  con- 
clusions should  leave  little  doubt  as  to  the  delusional  origin 
of  the  ideas  of  jealousy.  Indeed,  under  some  circumstances 
we  can  come  to  the  conclusion  that  a  jealousy  which  appears 
to  be  justified  by  real  circumstances,  nevertheless,  on  account 
of  its  peculiar  basis,  must  be  regarded  as  morbid.  This  is 
especially  clear  when  we  observe  how  the  patient  disregards, 
with  unconcern,  the  real,  open  adultery  of  the  wife,  while 
the  delusion  leads  to  passionate  outbreaks.  Delusions  of 
infidelity  may  occur  in  the  psychoses  of  the  period  of  in- 
volution and  occasionally  also  in  dementia  prsecox.  In 
general,  the  delusions  are  less  apt  to  be  fantastic  in  the  alco- 
holic psychosis,  and  there  are  lacking  the  physical  sensations, 
the  hallucinations,  and  the  nocturnal  experiences  which  are 
encountered  in  the  other  psychoses.  In  addition  to  this, 
there  is  a  striking  contrast  between  the  subsidence  of  the 
symptoms,  the  weakness  of  will  shown  by  the  alcoholic  upon 
enforced  abstinence,  and  his  brutality  and  animosity  when 
unrestrained.  This  psychosis  is  differentiated  from  paranoia 
by  the  lack  of  a  stable  systemization  of  the  delusions  and  by 
the  symptoms  of  chronic  alcoholism. 

Treatment.  —  In  these  cases  the  treatment  is  confined  to 
enforced  abstinence  and  careful  watching  or  confinement  in 
an  institution  to  prevent  assaults. 

Alcoholic  Paresis 

This  psychosis  represents  in  the  majority  of  cases  a  simple 
combination  of  the  symptoms  of  chronic  alcoholism  with 


ALCOHOLIC  PSEUDOPARESIS  201 

those  of  paresis.  There  is  added  to  the  defective  memory 
the  expansive  delusions  and  the  emotional  deterioration  of 
paresis,  the  hallucinations  and  delusions  of  infidelity  of  the 
alcoholic;  while  the  speech  disorder  of  the  paretic  is  accom- 
panied by  the  tremor  and  neuritic  disturbances  of  the  alco- 
holic. Epileptiform  attacks  also  are  particularly  numerous. 
Usually  the  signs  of  alcoholism,  have  existed  for  some  time 
before  the  paretic  symptoms  develop.  On  the  other  hand, 
the  initial  symptoms  may  lead  to  such  excessive  drinking 
that  the  alcoholic  symptoms  develop. 


Alcohol  Pseudoparesis 

There  are  included  here  severe  cases  of  alcoholic  halluci- 
natory dementia  with  more  or  less  pronounced  signs  of 
Korssakow's  psychosis,  in  which  physical  symptoms  pre- 
dominate, as,  tremor,  speech  disorder,  ataxia,  paralyses, 
rigid  pupils,  and  paralytic  attacks.  These  cases  are  dis- 
tinguished from  true  paresis  by  the  history  of  their  develop- 
ment, the  predominance  of  the  polyneuritic  symptoms,  the 
active  hallucinations,  and  the  more  prolonged  course,  which 
leads  to  a  simple  alcoholic  dementia  and  not  to  the  absolute 
dementia  and  death  that  characterizes  paresis. 


B.  MORPHINISM 

The  extensive  use  and  abuse  of  morphin  for  its  alluring 
effects  place  it  second  only  to  alcohol  in  the  production  of 
mental  and  physical  wrecks. 

Etiology.  —  The  intolerance  of  pain  among  people  of  this 
age,  together  with  the  laxity  of  the  physicians  in  dis- 
pensing analgesics,  accounts  in  part  for  the  extensive  use 
of  this  drug.  Being  an  expensive  drug,  its  victims  are 
limited  to  the  better  classes.  Considerably  over  one-half  of 
the  patients  are  those  who  are  best  acquainted  with  its  ill 
effects  —  physicians,  dentists,  and  professional  nurses.  At 
least  one-half  of  these  patients  are  men.  On  the  Continent 
it  is  claimed  that  seventy-five  per  cent,  are  men. 

An  important  etiological  factor  is  the  defective  constitu- 
tional basis,  evidences  of  which  in  very  many  cases  are  earlier 
manifested  by  various  neuroses,  as  hysteria.  Individuals 
free  from  this  hereditary  taint  usually  succumb  to  the  drug 
after  its  continued  employment  in  persistent  painful  affec- 
tions, as  neuralgia,  sciatica,  rheumatism,  headache,  dys- 
menorrhcea,  and  different  forms  of  colic.  The  pleasurable 
feeling  and  the  mental  stimulus  which  supplement  the 
analgesic  effects  are  here  the  cause  of  its  continuance.  The 
majority  of  cases  develop  between  the  ages  of  twenty-five 
to  forty  years. 

Pathological  Anatomy.  —  In  animals  to  which  morphin 

had  been  administered  for  a  prolonged  period,  Nissl  has 

demonstrated  a  shrinkage   of  cortical  neurones  with  an 

increase  of  the  neuroglia. 

202 


MORPHINISM  203 

Symptomatology.  —  Acute  Morphin  Intoxication.  —  The 
physiological  action  of  morphin  is  to  first  produce  an 
acceleration  and  excitation  of  the  process  of  comprehen- 
sion and  a  psychomotor  retardation,  which  later  passes  into 
a  befogged  state,  with  changing  fantastic  hallucinations  and 
an  intense  weariness  in  the  psychomotor  functions.  Then 
ensues  a  quiet,  pleasurable  feeling,  which  acts  as  one  of  the 
strongest  enticements  for  the  habitue.  For  him  it  also  pro- 
duces a  necessary  stimulus  for  mental  work,  which  cannot 
be  accomplished  by  the  exercise  of  the  will  power  alone. 
There  develops  a  metallic  taste  in  the  mouth,  and  sometimes 
rumbling  in  the  bowels.  Fortunately  the  drug  fails  to  pro- 
duce these  pleasurable  effects  for  all,  owing  to  idiosyncrasies. 
Many  after  its  exhibition  suffer  from  a  disagreeable  fulness 
in  the  head,  general  feeling  of  discomfort,  nausea,  and 
colicky  pains.  Following  the  intoxication  there  is  apt  to 
be  headache,  profuse  perspiration,  and  diminution  in  all  of 
the  secretions  of  the  body. 

Chronic  Morphin  Intoxication.  —  In  the  prolonged  use  of 
morphin  the  effects  of  acute  intoxication  disappear,  and  the 
individual  obtains  only  the  exhilarating  and  the  quieting 
effects,  which  aid  in  endurance  of  annoyance  incident  to 
his  work  or  his  home  life.  The  beneficial  effects  of  this 
drug  diminish  with  usage,  and  soon  necessitate  increased 
dosage,  which  may,  in  time,  reach  from  thirty  to  fifty  grains 
daily.    The  frequency  of  the  doses  must  also  be  increased. 

The  character  of  the  symptoms  and  the  time  of  their  ap- 
pearance depend  mostly  upon  the  individual  constitution 
and  its  powers  of  resistance.  Some  continue  addicted  to 
morphin  throughout  life  without  pronounced  ill  effect;  others 
succumb  in  the  course  of  a  few  months.  In  these  the  memory 
weakens,  and  the  capacity  for  mental  application  diminishes. 
Difficult  and  exhausting  work  becomes  impossible  without 


204  FORMS  OF  MENTAL  DISEASE 

its  administration.  Consequently  the  patients  are  either  in 
a  condition  of  exhilaration,  stupidity,  or  nervous  irritability, 
none  of  which  are  compatible  with  mental  work. 

Emotionally,  these  patients  exhibit  many  variations:  they 
are  sometimes  dejected,  irritable,  cross,  hypochondriacal; 
sometimes  confidential,  over-nice,  with  pronounced  affecta- 
tion; and  occasionally  anxious,  especially  at  night.  Morally, 
there  is  a  pronounced  change  of  character,  noticeable  es- 
pecially in  reference  to  their  irresistible  habit.  They 
willingly  submit  to  all  sorts  of  depraved  means  in  order  to 
secure  the  drug.  Finally  all  idea  of  personal  responsibility 
vanishes.  The  home  and  the  business  suffer  alike,  and  they 
fall  into  a  state  of  apathy  and  indolence,  with  an  absence  of 
will  power  and  energy.  They  are  careless  about  the  dress 
and  the  personal  appearance.  In  actions  they  are  apt  to 
be  sleepy  during  the  day,  and  active  and  restless  at  night, 
reading,  busying  themselves  about  foolish  trifles,  and  talk- 
ing incessantly.  They  are  also  disagreeable,  faultfinding, 
and  obstinate  to  the  extreme.  Very  many  of  them  become 
addicted  to  alcohol,  and  other  drug  habits. 

Physically,  the  sleep  is  much  disturbed.  The  patients  lie 
awake  for  hours,  their  minds  busied  with  all  sorts  of  fan- 
tastic ideas,  sometimes  accompanied  by  genuine  hallucina- 
tions of  sight.  Disturbances  of  sensibility  are  usually  pres- 
ent, such  as  paresthesias  and  hyperesthesias,  especially 
about  the  heart,  the  intestines,  and  the  bladder.  There  is 
usually  an  increase  of  the  tendon  reflexes.  The  movements 
are  uncertain,  tremulous,  and  sometimes  ataxic.  Occa- 
sionally there  is  difficulty  in  speech,  also  paresis  of  eye 
muscles  (double  vision  and  defective  accommodation).  The 
general  nutrition  suffers,  and  there  is  loss  of  weight.  The 
skin  is  flabby  and  dry,  due  in  part  to  the  absence  of  normal 
secretions.    The  appetite,  especially  for  meat,  fails,  though 


MORPHINISM  205 

sometimes  there  is  a  ravenous  appetite.  Dryness  of  the 
mouth  creates  unusual  thirst.  In  the  circulatory  system 
there  is  noticed  palpitation,  and  slow,  irregular  pulse.  The 
ringing  in  the  ears,  numbness,  vertigo,  and  syncope,  as  well 
as  the  profuse  perspiration  and  shivering,  are  attributable 
to  vasomotor  disturbances.  The  lack  of  sexual  desires  and 
impotence  are  prominent  symptoms;  in  women  there  is 
amenorrhcea  and  sterility.  The  ensemble  of  these  symptoms 
creates  the  picture  of  premature  senility. 

Abstinence  Symptoms.  —  The  abrupt  withdrawal  of  mor- 
phin  in  individuals  who  are  addicted  to  large  doses  produces 
in  the  course  of  a  few  hours  a  characteristic  train  of  symp- 
toms called  abstinence  symptoms.  These,  according  to 
Marme,  are  due  to  the  action  of  oxydimorphin.  The  with- 
drawal even  in  milder  cases  is  always  attended  with  more 
or  less  disturbance.  The  patients  become  tremulous 
and  uneasy,  experience  a  tickling  sensation  in  the  nose  and 
begin  to  sneeze;  feel  oppressed,  complain  of  paraesthesias  of 
different  parts  of  the  body,  and  are  sleepless.  The  adminis- 
tration of  hypnotics,  especially  chloral,  at  this  time,  only 
increases  the  excitement  and  aids  in  bringing  about  a 
delirious  condition  with  hallucinations  and  dreamy  confu- 
sion. In  spite  of  precaution,  however,  a  condition  very 
similar  to  delirium  tremens  may  appear.  This  condition 
lasts  but  a  few  hours,  or  at  most  a  few  days.  Occasionally 
there  appears  a  condition  of  dazedness,  with  hallucinations 
and  convulsive  movements.  Physically,  the  patients  display 
involuntary  movements,  twitchings  of  the  limbs,  spasm  of 
the  diaphragm,  paresis  of  the  muscles  of  accommodation, 
tenesmus,  paleness  and  flushing,  vomiting,  palpitation  of  the 
heart,  fainting  and  collapse  with  heart  failure,  which  is 
sometimes  fatal.  The  secretion  of  saliva  and  perspiration, 
which  during  the  ingestion  of  morphin  has  been  diminished, 


206  FORMS  OF  MENTAL  DISEASE 

now  becomes  excessive,  and  there  is  colliquative  diarrhoea. 
Albumen  is  usually  present  in  the  urine.  The  duration  and 
intensity  of  the  symptoms  depend  upon  the  constitution  of 
the  patient,  the  duration  of  the  habit,  and  the  size  of  the 
habitual  dose.  The  symptoms  disappear  gradually,  except 
in  the  lighter  cases,  where  they  may  vanish  rapidly  after  a 
prolonged  sleep.  In  the  course  of  a  few  days,  perhaps  weeks, 
the  patients  begin  to  sleep  and  develop  an  appetite,  but 
from  this  point  convalescence  progresses  very  slowly. 

Course.  —  The  rapidity  with  which  the  symptoms  of 
chronic  morphinism  develop  varies  with  the  power  of  re- 
sistance of  the  individual  and  the  quantity  of  morphin 
ingested;  in  some  cases  it  requires  a  few  months,  in  others 
several  years.  The  duration  also  varies;  some  die  within 
a  year  of  inanition,  heart  failure,  or  in  collapse,  while  others 
live  for  many  years  in  spite  of  large  and  increasing  doses. 

Diagnosis.  —  The  disease  may  be  recognized  by  the  vary- 
ing emotional  attitude;  periods  of  mental  freshness  and  un- 
usual energy  with  a  feeling  of  well-being,  alternating  with 
great  weariness,  stupidity,  dejection,  and  irritability,  and 
furthermore  by  the  physical  signs :  the  loss  of  sexual  power, 
anorexia,  myosis,  and  general  muscular  weakness,  amount- 
ing in  some  cases  almost  to  paresis.  Scars  from  the  hypo- 
dermic injections  should  always  be  looked  for.  The  surest 
means  of  diagnosis  is  seclusion  or  close  surveillance  for  a 
week,  during  which  time  the  demand  for  the  drug  or  some 
abstinence  symptoms  will  appear. 

Prognosis.  —  The  prognosis  is  always  very  serious.  Less 
than  ten  per  cent,  recover  permanently;  relapses  are  the 
rule.  A  few  cases  die  from  overdoses  of  the  drug.  The 
greater  danger  lies  in  cardiac  weakness,  which  may  lead  to 
sudden  collapse  and  fatal  termination.  The  drug  may  be 
withdrawn  with  the  proper  precautions  and  the  patients 


MORPHINISM  207 

suffer  no  ill-effects.  Often,  when  the  patients  do  not  re- 
lapse into  morphinism,  they  revert  to  substitutes,  of  which 
the  most  important  are  cocain,  alcohol,  chloroform,  ether, 
and  chloral.  The  treatment  is  preeminently  unsuccessful  in 
those  with  strong  neuropathic  tendencies. 

Treatment.  —  The  only  successful  method  of  treatment  is 
complete  abstinence.  For  this  purpose  the  first  requisite  is 
isolation  in  a  reputable  institution.  This  method  of  treat- 
ment, however,  cannot  be  safely  undertaken  in  all  cases, 
and  especially  where  conditions  of  physical  weakness  are 
present,  also  during  pregnancy,  acute  and  severe  chronic 
diseases.  There  are  two  methods  of  withdrawal,  the 
gradual  and  the  rapid,  the  latter  of  which  requires  the 
greatest  skill  and  is  by  far  the  most  efficacious.  The  former 
involves  much  time  and  patience,  and  is  apt  to  create  chronic 
and  disagreeable  traits  which  in  the  end  are  as  difficult  to 
eradicate  as  the  habit  itself.  For  these  reasons  only  the 
rapid  method  is  outlined  here.  It  is  necessary  that  the 
patients  be  placed  in  bed.  In  mild  cases  the  drug  may  be 
withdrawn  abruptly.  Even  in  these  the  abstinence  symp- 
toms may  appear.  In  cases  where  the  dose  has  been  large, 
the  quantity  is  immediately  reduced  one-half,  and  after 
twenty-four  hours  to  a  nominal  dose  of  one  grain  daily  for 
several  days,  and  in  the  course  of  two  weeks  entirely  with- 
drawn. During  the  period  of  withdrawal  the  drug  is  best 
given  in  single  daily  doses  in  the  early  evening.  If  pre- 
viously taken  hypodermically,  the  drug  should  at  once  be 
changed  to  administration  by  mouth.  Abstinence  symp- 
toms occur  within  the  first  thirty-six  to  forty-eight  hours 
after  the  withdrawal  of  the  drug  and  demand  careful  watch- 
ing on  the  part  of  the  physician.  To  guard  against  these 
and  to  add  to  the  comfort  of  the  patient,  alcohol  in  small 
doses  with  light  nutritious  diet  may  be  given.     Where  there 


208  FORMS  OF  MENTAL  DISEASE 

is  impending  collapse,  faradization  of  the  skin,  injections  of 
ether  or  camphor,  the  administration  of  hot  coffee  or  hypo- 
dermic injections  of  strophanthus  and  strychnia  are  indi- 
cated, the  last  of  which  is  often  essential.  If  these  fail, 
one  always  finds  immediate  relief  in  return  to  the  usual  dose 
of  morphin.  The  greatest  restlessness  and  insomnia  often 
yield  to  the  influence  of  ice  packs  on  the  head.  If  un- 
successful, the  various  hypnotics  may  be  tried.  The  local 
pains  may  also  be  relieved  by  the  application  of  ice.  Purga- 
tion should  be  applied  early;  this,  however,  is  contra- 
indicated  by  pregnancy  or  an  acute,  serious,  or  chronic 
disease.  Diarrhoea  demands  no  special  attention.  Finally, 
it  requires  many  months,  and  in  some  cases  a  year,  to  re- 
establish the  former  mental  and  physical  health  so  that 
they  are  able  to  return  to  their  old  associations  without 
fear  of  relapse.  Even  after  being  fully  reestablished  in 
health,  it  is  necessary  from  time  to  time  that  the  patients 
be  subjected  to  close  surveillance  to  ascertain  if  there  is  a 
return  to  the  old  habit. 


C.   COCAINISM 

Cocain,  in  distinction  from  alcohol  and  morphin  in  its 
effects,  is  characterized  by  the  great  rapidity  with  which  it 
produces  profound  mental  enfeeblement  and  physical  inani- 
tion. It  is  of  rare  occurrence  to  encounter  symptoms  of 
cocainism  alone,  because  of  the  frequency  of  its  complica- 
tion with  alcoholism  and  morphinism.  For  this  reason  it  is 
difficult  to  draw  a  pure  clinical  picture  of  the  disease. 

Etiology.  —  The  conditions  giving  rise  to  cocainism  are 
similar  to  those  encountered  in  morphinism.  Most  of  the 
patients  have  a  strong  neuropathic  basis,  and  many  of  them 
have- previously  been  addicted  to  morphin.  Early  in  the 
history  of  cocainism  the  habit  arose  from  the  substitution 
of  cocain  for  morphin  in  the  treatment  of  the  latter  habit, 
But  at  the  present  time  most  of  the  patients  are  physicians 
or  druggists.  The  usual  method  of  administration  is  by  the 
syringe,  although  it  may  be  taken  by  insufflation. 

Symptomatology.  —  Acute  Cocain  Intoxication.  —  Cocain  in 
small  doses  produces  moderate  mental  excitement,  with  a 
feeling  of  warmth  and  well-being,  increase  of  pulse  rate, 
and  a  fall  of  blood  pressure.  Its  effects  in  the  psychomotor 
field  are  similar  to  those  of  acute  alcoholic  intoxication:  an 
excitement  followed  by  paralysis.  The  patient  is  active, 
energetic,  feels  impelled  to  write,  and  is  talkative.  This 
condition  is  sooner  or  later  followed  by  drowsiness.  Large 
doses  lead  to  delirious  states  with  a  tendency  to  collapse. 
Nissl  has  found  in  experiments  upon  rabbits  that  in  the 

p  209 


210  FORMS  OF  MENTAL  DISEASE 

acute  intoxication  there  is  but  a  very  slight  alteration  in 
the  cortical  neurones;  i.e.  a  moderate  disintegration  of  the 
chromophilic  granules,  some  staining  of  the  achromatic 
substance,  and  a  moderate  increase  of  the  glia  cells. 

Chronic  Cocain  Intoxication.  —  In  one  accustomed  to  the 
prolonged  use  of  the  drug,  there  is  a  continuous  mental  state 
of  nervous  excitement  with  a  flight  of  ideas,  complete  in- 
capacity for  mental  work,  lack  of  will-power,  and  defective 
memory.  The  patients  are  overenergetic,  but  their  activity 
is  planless;  they  are  talkative  and  very  productive,  writing 
lengthy,  meaningless  letters,  and  evolving  on  paper  imprac- 
ticable schemes.  They  neglect  their  professional  and  home 
duties,  also  their  personal  appearance.  In  emotional  atti- 
tude there  is  a  variation  between  exhilaration  with  a  pro- 
nounced feeling  of  well-being  and  great  irritability  and 
anxiety.  They  are  very  apt  at  times  to  mistrust  their  sur- 
roundings. At  the  same  time  they  exhibit  more  or  less  in- 
difference as  to  the  legal  consequence  of  their  acts.  The 
memory  becomes  defective  and  the  judgment  much  im- 
paired. 

Physically,  the  most  prominent  symptom  is  the  profound 
disturbance  of  nutrition;  the  patients  lose  weight  very 
rapidly,  the  normal  expression  changes,  they  look  sleepy 
and  tired,  the  skin  becomes  flaccid  and  pale.  This  is  due 
in  part  to  the  fact  that  the  drug  supplies  the  place  of  nutri- 
tious food,  for  which  they  have  lost  all  desire,  and  in  part 
to  excessive  glandular  action  which  makes  a  continuous 
drain  upon  the  body  tissues.  There  is  muscular  weakness 
and  increased  myotatic  irritability,  noted  sometimes  in  the 
muscular  twitchings.  The  pupils  are  dilated,  but  react 
normally,  and  there  is  tremor  of  the  tongue.  In  the  cir- 
culatory system  there  is  slowness  of  the  pulse,  palpitation, 
and  a  tendency  to  faintness.     In  spite  of  increased  sexual 


COCAINISM  211 

excitement,  the  sexual  power  diminishes.  The  sleep  is  dis- 
turbed, and  occasionally  interrupted  by  hallucinations. 

Upon  the  basis  of  chronic  cocainism  there  may  develop 
a  definite  psychosis  which  bears  close  resemblance  to  the 
acute  alcoholic  hallucinosis. 

Acute  Cocain  Hallucinosis.  —  Following  a  few  days  of 
irritability  with  anxiety  and  some  restlessness,  there  appear 
suddenly  hallucinations  of  different  senses;  the  patients 
hear  threatening  voices  compelling  them  to  act  strangely, 
and  see  moving  pictures  on  the  wall,  which  are  filled  with 
large  and  small  objects.  Characteristic  of  the  hallucina- 
tions are  the  minute  black  specks  moving  about  on  a  light 
surface,  which  are  mistaken  for  flies,  mosquitoes,  and  other 
tiny  objects.  This,  according  to  Erlenmeyer,  is  an  evidence 
of  multiple  disseminated  scotoma.  Peculiar  sensations  in 
the  skin  create  the  belief  that  they  are  being  worked  upon 
by  electricity,  being  thrust  with  needles,  or  that  poisonous 
material  is  being  thrown  upon  them;  but  most  characteristic 
is  the  sensation  that  foreign  objects  are  under  the  skin, 
especially  at  the  ends  of  the  fingers  and  in  the  palms  of  the 
hands.  The  muscular  twitchings,  they  believe,  are  due  to 
the  action  of  some  poison.  The  hallucinations  of  hearing 
make  them  suspicious  of  their  surroundings.  Their  thoughts 
are  being  read  by  means  of  some  secret  contrivance;  they  are 
being  spied  through  holes  in  the  ceiling.  Some  patients  be- 
come so  thoroughly  frightened  that  they  attempt  to  kill 
their  supposed  persecutors,  or  in  despair  may  commit 
suicide. 

A  characteristic  symptom  is  the  silly  delusions  of  infidelity. 
These  are  frequently  obscene  in  character.  Wives  or 
husbands  are  accused  of  illicit  relations,  of  receiving  many 
love  letters,  of  stealthily  leaving  the  house  and  neglecting 
the  family  for  immoral  purposes,  or  of  becoming  known  as 


212  FORMS  OF  MENTAL  DISEASE 

public  characters.     In  reaction  to  these  ideas  patients  are 
usually  vindictive  and  may  even  become  aggressive. 

The  consciousness  remains  clear.  There  is  good  orienta- 
tion, except  in  rare  instances  where  the  excitement  is  very 
great,  or  immediately  following  fresh  injections  of  the  drug. 
In  emotional  attitude  patients  are  always  dejected,  excitable, 
irritable,  and  sometimes  passionate.  Occasionally  they  are 
reserved  and  reticent  concerning  their  delusions.  In  actions 
they  are  usually  very  restless  and  unstable,  though  some  may 
appear  quite  orderly.  In  the  markedly  delirious  conditions 
which  sometimes  appear  there  is  always  great  restlessness. 

Acute  cocain  hallucinosis  develops  rapidly  and  may  run 
its  full  course  within  a  few  weeks.  The  symptoms  increase 
rapidly  under  the  influence  of  single  doses  of  cocain.  The 
delirious  state  soon  disappears  after  the  complete  with- 
drawal of  the  drug,  sometimes  within  a  few  days,  while  the 
delusions  may  remain  for  weeks  or  even  months.  The  co- 
existence of  morphinism  and  cocainism  in  the  same  indi- 
vidual, which  is  of  common  occurrence,  frequently  leads  to 
a  combination  of  the  symptoms.  Morphinism  alone  seldom 
produces  a  rapid  development  of  pronounced  mental  dis- 
turbance, unless  in  connection  with  cocainism. 

Acute  cocain  hallucinosis  is  differentiated  from  acute 
alcoholic  hallucinosis  by  its  more  rapid  development,  the 
greater  severity  of  the  symptoms,  and  by  the  fact  that  the 
delusions  of  jealousy  appear  earlier  and  as  an  acute  symp- 
tom. The  effect  of  a  single  dose  of  cocain  during  the  psy- 
chosis produces  an  exacerbation  of  the  symptoms,  while  in 
alcoholism  it  has  little  or  no  effect.  Finally,  the  sensation 
of  objects  under  the  skin  is  characteristic  only  of  cocainism. 

The  prognosis  in  cocainism  is  unfavorable  for  complete 
recovery.  The  symptoms  of  intoxication  clear  up  after  the 
withdrawal  of  the  drug,  but  the  power  of  resistance  is  pro- 


COCAINISM  213 

foundly  affected,  and  few  resist  temptation  for  any  great 
length  of  time. 

Treatment.  —  The  only  successful  method  of  treatment 
is  complete  abstinence.  The  rapid  method  of  the  with- 
drawal, similar  to  that  employed  in  morphinism,  is  best. 
The  withdrawal  is  usually  attended  only  by  unimportant 
symptoms,  such  as  uneasiness,  a  feeling  of  pressure  in  the 
chest,  with  difficulty  in  breathing,  also  palpitation  of  the 
heart,  and  insomnia,  and  occasionally  by  a  tendency  to 
f aintness  which  simulates  collapse.  If  such  emergency  arises, 
it  is  necessary  to  employ  stimulants,  as  alcohol,  camphor, 
coffee,  strychnia,  etc.  The  insomnia  may  be  combated  with 
prolonged  warm  baths,  paraldehyde  trional,  and  also  by  a 
nutritious  diet.  An  essential  element  in  successful  treat- 
ment is  confinement  in  an  institution,  where  it  can  be  deter- 
mined with  certainty  that  the  patient  does  not  have  access 
to  the  drug.  Prolonged  treatment  with  the  employment  of 
every  possible  means  to  fortify  him  against  relapses  is  an 
important  factor,  which  requires  patience  on  the  part  of  the 
patient  and  perseverance  and  tact  on  the  part  of  the  phy- 
sician. If  morphinism  and  cocainism  coexist,  cocain  should 
be  withdrawn  first. 


IV.  THYROGENOUS  PSYCHOSES 

The  two  forms  of  psychosis  arising  from  disturbance  of 
the  thyroid  gland  are  myxedematous  insanity  and  cretinism. 
They  develop  directly  as  the  result  of  an  absence  of  glandu- 
lar activity,  cretinism  appearing  in  early  childhood,  and 
myxcedematous  insanity  in  adolescence  and  later.  Right- 
fully the  symptoms  accompanying  Graves's  disease  belong  in 
this  group,  but  are  not  described  because  of  their  com- 
paratively infrequent  occurrence. 

A.  Myxcedematous  Insanity 

The  mental  disturbance  characteristic  of  myxcedema  is 
that  of  a  simple  progressive  mental  deterioration  accom- 
panied by  the  characteristic  physical  symptoms  of  the 
disease. 

Etiology.  —  The  lack  of  glandular  activity  in  the  thyroid 
is  supposed  to  be  the  exciting  cause  by  failing  to  neutralize 
or  care  for  some  toxic  product  of  metabolism.  The  gland 
in  all  cases  is  found  atrophied  or  diseased.  This  is  fre- 
quently the  result  of  connective  tissue  increase,  sometimes 
of  colloid  degeneration,  and  rarely  of  tuberculosis  or  syphilis 
of  the  gland. 

Symptomatology.  —  The  onset  of  the  mental  disturbance 
is  gradual,  with  increasing  difficulty  of  apprehension.  The 
patients  do  not  comprehend  written  or  spoken  language  as 
well  as  formerly,  and  are  unable  to  collect  their  thoughts. 
It  takes  them  longer  to  perform  ordinary  duties,  such  as 

214 


THYROIGEXOUS  PSYCHOSES  215 

dressing,  and  they  also  tire  easily.  Memory  for  recent  events 
becomes  defective.  The  increasing  difficulty  in  applying  the 
mind  and  in  performing  even  simple  acts  finally  renders 
them  completely  helpless.  There  is  no  clouding  of  con- 
sciousness. At  first  they  exhibit  some  insight  into  their 
defects,  but  later  this  gives  way  to  indifference  and  stupidity, 
not  only  in  reference  to  themselves  and  their  condition,  but 
also  to  their  environment.  They  rarely  express  pleasure  or 
pain,  and  very  seldom  give  evidence  of  thought  for  them- 
selves or  their  future.  In  emotional  attitude  it  is  characteris- 
tic for  them  to  be  anxious,  dejected,  and  at  times  fearful- 
Sometimes  they  develop  restlessness,  and  moderate  excite- 
ment with  stubbornness.  In  rare  cases  there  may  appear 
conditions  of  confusion  with  hallucinations  and  delusions. 

Physically,  they  present  characteristic  cutaneous  and 
nervous  symptoms.  The  skin  becomes  thick  and  dry, 
rough,  inelastic,  obliterating  the  characteristic  lines  of  ex- 
pression in  the  face,  producing  thick  lips,  broad  nose,  and 
deforming  the  hand  and  fingers.  The  mucous  membrane 
is  similarly  involved,  and  the  tongue  is  thick  and  unwieldy. 
The  cutaneous  change  is  most  marked  in  the  supraclavi- 
cular region,  in  the  upper  arms,  and  in  the  abdominal  wall. 
The  voice  is  changed,  becoming  rough  and  monotonous,  and 
the  speech  is  slow  and  difficult.  The  nervous  symptoms  con- 
sist chiefly  of  headache,  vertigo,  fainting,  convulsive  spells, 
and  a  fine  tremor.  Finally  the  skin  and  mucous  membrane 
become  anaemic  and  very  sensitive  to  cold,  menses  cease, 
and  temperature  becomes  subnormal.  The  blood  changes 
vary;  sometimes  there  is  an  increase  of  the  red  corpuscles, 
and  at  other  times  a  diminution. 

Course.  —  The  psychosis  is  of  gradual  onset,  and  unless 
appropriate  treatment  is  applied,  progresses  to  advanced 
deterioration,  extreme  physical  weakness,  and  profound  dis- 


216  FORMS  OF  MENTAL  DISEASE 

turbance  of  nutrition,  the  disease  terminating  fatally  through 
the  intervention  of  some  intercurrent  disease.  Occasionally 
there  are  intermissions,  and  in  a  few  cases  marked  improve- 
ment occurs  in  spite  of  the  absence  of  treatment. 

Treatment.  —  The  administration  of  dried  thyroids  of  the 
sheep,  beginning  at  one  and  one-half  grains,  one  to  three 
times  daily,  may  be  regarded  as  a  specific  remedy  in  this 
disease.  The  dose  is  gradually  increased,  guarding  carefully 
against  intoxication  symptoms,  indicated  by  headache,  dizzi- 
ness, and  irregular  cardiac  action.  The  improvement  be- 
comes evident  within  a  week  and  increases  very  rapidly. 
The  patients  become  active  and  show  an  interest  in  them- 
selves and  surroundings;  they  improve  in  memory  and  in 
judgment.  The  physical  symptoms  improve  with  equal 
rapidity.  In  the  most  successful  cases  the  patients  appear 
quite  well  at  the  end  of  two  months,  except  for  some  lassi- 
tude, which  persists  for  a  long  time.  Not  all  cases  recover 
through  medication;  the  number  of  unsuccessful  cases  is 
difficult  to  ascertain  at  present.    Relapses  may  occur. 

B.  Cretinism 

Cretinism  is  characterized  by  a  more  or  less  high-grade 
defective  mental  development,  associated  with  loss  of  func- 
tion of  the  thyroid,  and  accompanied  by  definite  physical 
symptoms. 

Etiology.  —  The  disease  is  mostly  endemic  in  mountain- 
ous regions.  In  Europe  the  cases  are  most  numerous  in 
the  Alps  and  Pyrenees;  in  America,  in  Vermont.  Sporadic 
cases  occur  as  the  result  of  congenital  absence  of  the  gland 
or  its  atrophy  during  or  following  a  fever,  or  in  connection 
with  goitre.  The  disease  arises  from  an  organic  infectious 
material,  and  is  in  some  way  associated  with  disease  of  the 
parathyroid  gland.    It  is  unknown  whether  this  infectious 


THYROIGENOUS  PSYCHOSES  217 

organism  is  the  cause  of  an  atrophy,  a  non-development,  or 
disease  of  these  glands,  in  this  way  producing  a  failure  of 
mental  development;  or  whether  it  is  due  to  the  direct 
action  of  the  organism  or  its  toxin  upon  the  nervous  system. 
Other  important  factors  are  defective  neuropathic  basis  and 
unhygienic  surroundings. 

Pathological  Anatomy. — The*  morbid  anatomy  is  still 
doubtful.  Asymmetries  and  dilatation  of  the  ventricles  of 
the  brain  and  atrophy  have  been  found,  also  hyperostosis  of 
the  cranium.  The  cortical  neurones  are  deficient  in  num- 
ber and  processes,  and  are  of  the  stunted  globose  form 
peculiar  to  idiocy  and  other  forms  of  defective  development. 

Symptomatology.  —  The  symptoms  of  the  disease  are  first 
noticed  during  the  first  and  second  years,  except  in  a  few 
cases  where  the  children  are  born  goitrous.  At  that  time 
they  appear  dull,  stupid,  indifferent,  sleepy,  and  unable  to 
care  for  themselves;  have  not  learned  to  walk  or  talk,  and 
are  slow  and  awkward  in  their  movements.  The  gland  in- 
creases in  size  from  the  sixth  to  twelfth  year  in  three-fourths 
of  the  cases;  in  the  remaining  it  diminishes.  Mentally,  the 
patients  fail  to  develop,  presenting  the  symptoms  of  im- 
becility; they  are  dull,  stupid,  incapable  of  apprehending  or 
of  elaborating  impressions,  presenting  about  the  capacity  of 
a  five-year-old  child.  They  are  rather  indifferent  and  phleg- 
matic, and  quite  incapable  of  applying  themselves  to  any 
work.  A  few  cases  present  a  condition  of  extreme  stupidity. 
Their  condition  remains  unchanged  throughout  life,  except 
as  interrupted  by  short  periods  of  excitement,  similar  to 
those  occurring  in  idiocy.  This  condition  may  form  a  basis 
for  the  development  of  other  psychoses,  especially  manic- 
depressive  insanity. 

Physically,  the  long  bones  fail  to  develop  in  length,  in- 
stead, becoming  thicker.    The  head  is  large,  and  the  neck 


218  FORMS  OF  MENTAL  DISEASE 

short  and  thick.  The  nose  is  broad,  and  the  ears  are  promi- 
nent, the  skin  is  thickened  as  if  padded,  and  in  places, 
especially  in  the  neck,  hanging  dependent  in  folds.  The 
broad  face,  with  heavy  cheeks  and  eyelids,  with  thick  lips 
and  broad  short  nose,  presents  a  very  characteristic  picture. 
The  limbs  are  large  and  pudgy.  The  tongue  is  thick  and 
clumsy  in  its  movements.  The  hair  is  scanty,  and  dentition 
is  late  and  the  teeth  poor.  The  speech  consists  of  inarticu- 
late sounds,  which  are  loud,  coarse,  slurring,  and  stammer- 
ing. The  movements  are  unwieldy,  the  gait  slow  and  cum- 
bersome. Convulsions  are  rare.  The  sexual  organs  develop 
slowly,  and  in  severe  cases  remain  entirely  undeveloped. 
Patients  have  little  power  of  resistance,  readily  succumbing 
to  intercurrent  diseases. 

Treatment.  —  The  hygienic  surroundings  must  be  im- 
proved with  special  attention  to  drinking  water.  Many 
observers  agree  that  it  is  advisable  as  a  prophylactic  measure 
to  send  children  and  families  with  cretinoid  tendencies  to 
the  high  mountains,  which  may  bring  about  a  complete 
recovery  in  children  who  already  show  some  signs  of  disease. 
Potassium  iodide  in  small  doses  seems  to  be  beneficial. 
According  to  recent  observation  the  administration  of  desic- 
cated thyroid,  if  given  early,  may  aid  in  preventing  the 
development  of  the  disease.  After  an  extended  duration  the 
same  drug  may  improve  some  of  the  physical  symptoms,  — 
thickness  of  the  skin  and  amenorrhcea,  —  but  the  mental 
symptoms  cannot  be  altered. 


V.  DEMENTIA  PRECOX 

Dementia  Precox  *  is  the  name  provisionally  applied  to 
a  large  group  of  cases  which  are  characterized  in  common  by 
a  pronounced  tendency  to  mental  deterioration  of  varying 
grades.  The  disease  apparently  develops  on  the  basis  of 
a  severe  disease  process  in  the  cerebral  cortex,  but  whether 
the  process  is  always  the  same  is  by  no  means  certain. 
Dementia  fortunately  does  not  occur  in  all  cases,  but  it  is 
so  prominent  a  feature  that  the  name  dementia  prsecox  is 
best  retained  until  the  symptom  group  is  better  understood. 

Etiology.  —  The  disease  is  one  of  the  most  prominent, 
comprising  from  fourteen  to  thirty  per  cent,  of  all  admis- 
sions to  insane  institutions.  As  the  name  indicates,  it  is 
a  disease  of  early  life.  More  than  sixty  per  cent.2  of  the 
cases  appear  before  the  twenty-fifth  year.  This,  however, 
varies  in  the  different  forms;  in  hebephrenia  almost  three- 

1  Finzie  Vedrani,  Rivista  sperim.de  freniatria,  XXV,  1899;  Chris- 
tian, Ann.  medico-psychol.  8,  9,  43,  1899;  Trcemmer,  Das  Jugendirresein 
(Dementia  prsecox),  1900;  Serieux,  Gaz.  hebdomad.  Mars  1901 ;  Revue 
de  psychiatrie,  Juin  1902;  Jahrmserker,  Zur  Frage  der  Dementia  prsecox, 
1902;  Meeus,  Bull,  de  la  soc.  de  med.  ment.  de  Belgique,  mars-sept. 
1902;  Masselon,  Psychologie  des  dements  precoces,  1902;  Stransky, 
Jahrb.  f.  Psych.  XXIII,  1903;  Bernstein,  Allg.  Zeitschr.  f.  Psych.  LX, 
554,  1903 ;  Meyer,  British  Medical  Journal,  Sept.  29,  1906. 

2  In  our  experience  in  Connecticut  the  age  of  onset  has  been  under  25 
years  of  age  in  only  34  %  of  the  cases ;  in  the  hebephrenic  form  45  % 
develop  the  disease  under  25  years  of  age,  in  the  catatonic  form  38  %, 
and  in  the  paranoid  only  11  %.  The  average  age  of  onset  in  all  forms  is 
from  one  to  four  years  earlier  in  the  male  than  in  the  female  patients. 

219 


220  FORMS  OF  MENTAL  DISEASE 

fourths  of  the  cases  appear  before  the  twenty-fifth  year, 
in  catatonia  sixty-eight  per  cent.,  and  in  the  paranoid  only 
forty  per  cent.  On  the  other  hand,  cases  that  cannot  in 
any  way  be  distinguished  from  hebephrenia  have  been  ob- 
served in  patients  between  fifty  and  sixty  years.  The  dis- 
ease in  the  younger  cases  seems  to  take  the  form  of  a  simple 
gradually  progressive  deterioration;  in  the  somewhat  later 
periods,  it  assumes  the  acute  and  subacute  forms  with 
catatonic  symptoms ;  while  still  later  the  more  pronounced 
delusion  formation  appears.  Kraepelin  reports  that  in  the 
hebephrenic  form  sixty-four  per  cent,  of  the  cases  are  men, 
in  catatonic  and  paranoid  forms  women  slightly  predominate; 
but  in  our  experience  men  slightly  predominate  in  the  hebe- 
phrenic and  catatonic  forms,  while  in  the  paranoid  form 
sixty-nine  per  cent,  are  women.  Defective  heredity  is  a 
very  prominent  factor,  as  it  appears  in  about  seventy  per 
cent,  of  cases  reported  by  Kraepelin,  but  in  not  more  than 
fifty-two  per  cent,  of  our  cases.  It  varies  somewhat  in  the 
different  forms,  being  far  more  prominent  in  the  paranoid 
and  equally  less  prominent  in  the  catatonic  and  hebephrenic 
forms.  Various  physical  stigmata  are  occasionally  encoun- 
tered, such  as  asymmetries  and  malformations  of  the  skull, 
ears,  and  palate,  puerile  expression,  strabismus,  super- 
numerary nipples,  general  physical  weakness.  There  is 
frequently  an  earlier  history  of  deliria  accompanying  mod- 
erate forms  of  fever,  of  convulsions  in  youth,  and  great  sus- 
ceptibility to  alcohol,  as  well  as  the  absence  of  sexual 
impulses  and  their  early  or  unnatural  development.  Besides 
the  above  evidences  of  a  faulty  endowment  thirty-three 
per  cent,  of  the  patients  previous  to  the  onset  of  the  disease 
have  been  only  moderately  bright.  At  least  twenty  per  cent, 
exhibit  mental  peculiarities  from  early  youth  up,  such  as 
seclusiveness,    affectation,    eccentricity,    precocious    piety, 


DEMENTIA  PRECOX  221 

impulsiveness,  and  moral  instability,  while  seven  per  cent, 
have  always  been  weak-minded.  In  women,  child-bearing 
seems  an  important  factor,  as  twenty-four  per  cent,  of  the 
female  catatonics  become  afflicted  during  pregnancy,  or 
at  childbirth,  but  particularly  the  latter.  This  occurs  in 
only  nine  per  cent,  of  the  female  hebephrenics.  In  ten  per 
cent,  of  the  cases  there  is  a  previous  history  of  some  severe 
acute  illness,  particularly  typhoid  and  scarlet  fevers,  from 
which  time  the  patients  have  exhibited  some  change,  as 
increased  irritability,  susceptibility  to  fatigue,  and  im- 
pairment of  the  full  mental  capacity.  Head  injuries  pre- 
cede a  very  small  number  of  cases.  Alcoholism,  likewise, 
is  an  unimportant  factor,  but  more  than  five  per  cent,  of 
the  male  patients  develop  their  disease  while  incarcerated 
in  prison.  These  and  the  puerperal  cases  are  particularly 
apt  to  develop  into  acute  and  subacute  forms.  Pregnancy 
favors  the  paranoidforms ;  and  child-bed,  the  catatonic  forms. 
Pathology.  —  The  nature  of  the  disease  process  in  de- 
mentia prsecox  is  not  known,  but  it  seems  probable,  judging 
from  the  clinical  course,  and  especially  in  those  cases  where 
there  has  been  rapid  deterioration,  that  there  is  a  definite 
disease  process  in  the  brain,  involving  the  cortical  neurones. 
This  view  is  further  upheld  by  the  fact  that  in  those  cases 
which  have  been  subjected  to  the  most  modern  methods 
of  research,  anatomical  lesions  have  been  found  which  can 
be  explained  only  upon  such  a  basis.  In  a  few  cases  this 
is  a  reparable  lesion,  but  in  most  cases  the  impairment  of 
function  is  permanent  and  progressive.  This  pathological 
basis  finds  clinical  expression  in  the  few  cases  that  recover 
and  the  larger  number  that  show  a  permanent  mental  de- 
fect. The  means  by  which  these  assumed  changes  are  brought 
about  in  the  nervous  system  are  no  better  known  than  those 
that  exist  in  epilepsy  and  idiocy.   The  relationship  of  the  dis- 


222  FORMS  OF  MENTAL  DISEASE 

ease  to  puberty,  disturbances  of  menstruation,  child-bearing, 
and  climacterium,  and  the  absence  of  every  recognizable  ex- 
ternal cause,  suggests  first  of  all  an  autointoxication,  which 
may  be  in  some  way  related  to  processes  in  the  sexual  organs. 
Defective  heredity,  which  exists  in  such  a  large  percentage 
of  cases,  may  be  presumed  to  create  a  lessened  power  of 
resistance  to  the  essential  causes  of  the  disease. 

Symptomatology.  —  In  the  field  of  apprehension  there  is 
usually  very  little  disturbance.  Ordinary  external  impressions 
are  correctly  apprehended,  the  patients  being  able  to  recognize 
their  environment  and  to  comprehend  most  of  what  takes 
place  about  them.  Yet  accurate  tests  show  that  very  brief 
stimuli  are  not  well  apprehended.  During  the  acute  or 
subacute  onset  of  the  disease,  apprehension  is  affected,  and 
there  is  some  disorientation.  This  may  also  appear  during 
transitory  stupor  or  excitement;  but  even  in  these  condi- 
tions, and  especially  in  the  apparent  stupidity  and  indiffer- 
ence which  characterize  the  later  stages  of  the  disease,  it 
is  surprising  to  see  how  many  things  in  the  environment  are 
apprehended.  Indeed,  it  is  not  unusual  to  find  that  patients 
even  notice  changes  in  the  physician's  apparel,  in  the  fur- 
niture, etc.  Nevertheless,  as  the  disease  advances  and 
deterioration  appears,  apprehension,  as  well  as  other  mental 
phenomena,  becomes  perceptibly  impaired. 

The  orientation  is  mostly  undisturbed.  Patients  usually 
know  where  they  are,  recognize  those  about  them,  and  are 
aware  of  the  time.  In  stupor  and  in  states  of  anxiety,  the 
orientation  may  be  considerably  clouded,  yet  it  is  character- 
istic of  dementia  prsecox  that,  even  in  spite  of  considerable 
excitement,  the  patients  continue  to  apprehend  well.  On 
the  other  hand,  the  delusional  form  of  disorientation  may 
exist  (see  p.  28). 

Apprehension  is  always  more  or  less  distorted  by  halluci- 


DEMENTIA  PRECOX  223 

nations,  especially  in  acute  and  subacute  development  of 
the  disease.  Occasionally,  they  persist  throughout  the 
entire  course  of  the  disease.  They,  however,  tend  to  dis- 
appear in  the  end  stages,  though  they  occasionally  reappear 
during  exacerbations.  Hallucinations  of  hearing  are  most 
prominent,  next  come  hallucinations  of  sight  and  touch, 
the  feelings  of  currents,  of  movements,  and  of  influence. 
Hallucinations  at  first  are  distressing,  and  result  in  fear; 
but  later  they  do  not  excite  much  reaction,  except  during 
exacerbations. 

Consciousness  is  usually  clear,  but  in  conditions  of  excite- 
ment and  stupor  there  is  always  some  clouding  of  conscious- 
ness. It  is,  however,  much  less  marked  than  one  would 
judge  from  superficial  observation,  as  the  patients  later  are 
able  to  give  some  details  of  things  that  happened  in  the 
interval. 

On  the  other  hand,  there  is  pronounced  impairment  of 
voluntary  attention,  which  is  one  of  the  most  fundamental 
symptoms.  The  controlling  force  of  interest  is  altogether 
lacking,  so  that  the  presentation  which  happens  to  be  the 
clearest  and  most  distinct  at  any  given  moment  is  an  acci- 
dent of  passing  attention,  never  persistent  enough  to  occa- 
sion connected  activity.  In  spite  of  the  fact  that  the  pa- 
tients perceive  objects  about  them  correctly,  they  do  not 
observe  them  closely  or  attempt  to  understand  them.  In 
deep  stupor  and  in  the  stage  of  deterioration  it  is  absolutely 
impossible  to  attract  the  attention  in  any  way.  In  the 
catatonic  form  of  dementia  prsecox  the  presence  of  nega- 
tivism inhibits  all  active  attention.  This  becomes  evident 
as  the  negativism  gradually  disappears.  The  patients 
emerging  from  this  condition  are  caught  stealthily  peeping 
about  when  unobserved,  looking  out  of  open  doors  or  win- 
dows, and  following  the  movements  of  the  physician,  but 


224  FORMS  OF  MENTAL  DISEASE 

when  an  object  is  held  before  them  for  observation  they 
stare  vacantly  about  or  close  their  eyes  tightly. 

There  is  a  characteristic  and  progressive,  but  not  profound, 
impairment  of  memory  from  the  onset  of  the  disease.  Mem- 
ory images  formed  before  the  onset  of  the  disease  are  retained 
with  remarkable  persistence,  —  retention  is  good.  Though 
their  reproduction  is  increasingly  more  difficult,  unusual 
stimulation  or  excitement  may  occasion  the  recollection 
of  events  long  since  supposed  to  be  effaced  by  the  advance 
of  deterioration — recollection  is  not  free.  The  formation  of 
new  memory  images  is  increasingly  difficult  with  the  ad- 
vance of  the  disease.  Memory  for  recent  events  is  poor. 
Events  previous  to  the  onset,  especially  school  knowledge, 
may  be  recalled  after  the  patients  show  advanced  deteriora- 
tion. Some  few  patients  keep  a  careful  account  of  the  length 
of  their  residence  in  the  hospital  and  elsewhere.  Events 
during  stupor  and  excitement  are  not  remembered  at  all, 
or  at  most  indistinctly. 

The  train  of  thought  sooner  or  later  in  the  course  of  the 
disease  is  profoundly  disturbed  by  the  appearance  of  a  char- 
acteristic looseness  and  desultoriness,  which  has  already  been 
described  (see  p.  40).  One  finds  even  in  the  mild  cases  some 
distractibility,  a  rapid  transition  from  one  thought  to  another 
without  an  evident  association,  and  interpolation  of  high- 
sounding  phrases.  In  severe  cases  there  is  genuine  confusion 
of  thought  with  great  incoherence  and  the  production  of  new 
words.  In  cases  of  the  catatonic  form  especially,  we  meet  with 
evidences  of  stereotypy;  the  patients  cling  to  one  idea,  which 
they  repeat  over  and  over  again.  Besides,  there  is  occasionally 
noticed  a  tendency  to  rhyme  or  repeat  senseless  sounds. 

In  judgment  there  appears  from  the  onset  a  progressive 
defect.  While  patients  are  able  to  get  along  without  diffi- 
culty under  familiar  circumstances,  they  fail  to  adapt  them- 


DEMENTIA  PRECOX  225 

selves  to  new  conditions.  Owing  to  their  inability  to  grasp 
the  meaning  of  their  surroundings,  their  actions  are  irra- 
tional. This  condition  of  defective  judgment  becomes  the 
basis  for  the  development  of  delusions.  The  patients  be- 
lieve that  they  are  the  objects  of  persecution,  and  they  may 
have  delusions  of  reference  and  self-accusation.  The  lack 
of  judgment  becomes  still  more  apparent  in  the  silliness 
of  their  delusions.  At  first  the  delusions  may  be  rather 
stable,  but  later  they  tend  to  change  their  content  fre- 
quently, adding  new  elements  suggested  by  the  environment. 
Even  relatively  persistent  delusions  are  constantly  taking 
on  new  meanings.  Furthermore,  the  delusions,  which  at 
first  are  of  a  depressive  nature,  later  may  become  ex- 
pansive and  grandiose.  In  most  cases  the  wealth  of  delu- 
sions so  apparent  at  first  gradually  disappears.  A  few 
delusions  may  be  retained  with  further  elaboration  from 
time  to  time,  but  they  are  usually  expressed  only  at  random. 
During  exacerbations  the  former  delusions,  whether  depres- 
sive or  expansive,  may  again  come  to  the  foreground.  In 
the  paranoid  forms,  however,  there  persists  from  the 
beginning  a  great  wealth  of  delusions,  but  these  become 
more  and  more  incoherent. 

The  disturbance  of  the  emotional  field  is  another  of  the  w 
characteristic  and  fundamental  symptoms.  There  is  a  pro- 
gressive, more  or  less  high-grade,  deterioration  of  the  emo- 
tional life.  The  lack  of  interest  in  the  surroundings  already 
spoken  of  in  connection  with  the  attention  may  be  regarded 
as  one  phase  of  the  general  emotional  deterioration.  Very 
often  it  is  this  symptom  which  first  calls  attention  to  the 
approaching  disease.  Parents  and  friends  notice  that  there 
is  a  change  in  the  disposition,  a  laxity  in  morals,  a  disregard 
for  formerly  cherished  ideas,  a  lack  of  affection  toward  rela- 
tives and  friends,  an  absence  of  their  accustomed  sympathy, 


226  FORMS  OF  MENTAL  DISEASE 

and  above  all  an  unnatural  satisfaction  with  their  own 
ideas  and  behavior.  They  fail  to  exhibit  the  usual  pleasure 
in  their  employment, 
v.  As  the  disease  progresses  the  absence  of  emotion  becomes 
more  marked.  The  patients  express  neither  joy  nor  sorrow, 
have  neither  desire  nor  fears,  but  live  from  one  day  to  another 
quite  unconcerned  and  apathetic,  sometimes  silently  gazing 
into  the  distance,  at  others  regarding  their  surroundings 
with  a  vacant  stare.  They  are  indifferent  as  to  their  per- 
sonal appearance,  submit  stupidly  to  uncomfortable  posi- 
tions, and  even  prodding  with  a  needle  may  not  excite  a 
reaction.  Food,  however,  continues  to  attract  them  until 
deterioration  is  far  advanced.  Indeed,  it  is  not  unusual 
to  see  these  patients  go  through  the  pockets  and  bundles 
of  their  friends  for  delicacies,  without  expressing  a  sign  of  rec- 
ognition. This  condition  of  stupid  indifference  may  be 
interrupted  by  short  periods  of  irritability. 

Early  in  the  disease,  and  especially  during  an  acute  and 
subacute  development,  the  emotional  attitude  may  be  one 
of  depression  and  anxiety.  This  may  later  give  way  to 
moderate  elation  and  happiness.  The  latter,  however,  in 
a  few  instances  prevails  from  the  onset.  Yet  emotional 
deterioration  remains  a  fundamental  symptom. 

Parallel  with  the  emotional  disturbances  are  found  dis- 
turbances of  conduct,  of  which  the  most  fundamental  is 
the  progressive  disappearance  of  voluntary  activity.  One 
of  the  first  symptoms  of  the  disease  may  be  the  loss  of  that 
activity  which  is  peculiar  to  the  patient.  He  may  neglect 
his  duties  and  sit  unoccupied  for  the  greater  part  of  the  day, 
though  capable  of  doing  good  work  if  persistently  encouraged. 
Besides  this  characteristic  inactivity,  there  may  appear  a 
tendency  to  impulsive  acts.  The  patients  break  out  win- 
dow lights,  tear  their  clothing  into  strips,  leap  into  the  water, 


DEMENTIA  PRECOX  227 

break  furniture,  throw  dishes  on  the  floor,  or  injure  fellow- 
patients,  all  of  which  seems  done  without  a  definite  motive. 
These  states  usually  pass  off  very  quickly,  though  in  some 
this  tendency  may  be  more  marked  for  a  period  of  a  few 
days. 

The  inability  to  control  the  impulses  is  also  present  in  the 
stuporous  conditions,  and  especially  in  the  catatonic  form  of 
dementia  prsecox.  Here  each  natural  impulse  is  seemingly  y 
met  and  overcome  by  an  opposing  impulse,  giving  rise  to 
actions  directly  opposite  to  the  ones  desired.  In  this  con- 
dition, which  is  called  negativism,  the  patients  resist  every- 
thing that  is  done  for  them,  such  as  dressing  and  undressing, 
they  refuse  to  eat  when  food  is  placed  before  them,  to  open 
their  mouth  or  eyes  when  requested,  or  to  move  in  any  direc- 
tion. In  extreme  conditions  there  may  even  be  retention 
of  urine  and  feces.  This  condition  varies  considerably  in 
intensity  at  different  times.  It  is  not  unusual  to  see  the 
patients  suddenly  relieved  of  it,  assume  their  former  activity, 
talking  freely  and  attending  to  their  own  needs,  and  again 
after  an  interval  of  a  few  hours  or  days  relapse  gradually 
into  the  negativistic  state. 

Still  another  condition  is  produced  by  the  repeated  re- 
currence of  the  same  impulse,  giving  rise  to  a  great  variety  v 
of  stereotyped  movements  and  expressions.  The  verbigera- 
tions and  mannerisms  of  the  catatonic  are  explained  in  this 
way.  The  patients  repeat  for  hours  similar  expressions, 
utter  monotonous  grunts,  tread  the  floor  in  the  same  spot, 
dress,  undress,  and  eat  in  a  peculiar  and  constrained  manner. 
While  these  symptoms  vary  considerably  in  individual  cases, 
it  is  unusual  not  to  find  at  least  some  of  them  present  in 
every  case. 

Frequently  also  hypersuggestibility  of  the  will  and  autom-  y 
atism  are  present,  particularly  in  the  stage  of  deterioration. 


228  FORMS  OF  MENTAL  DISEASE 

The  patients  are  not  only  very  pliable,  but  they  may  show 
echolalia  or  echopraxia  for  longer  or  shorter  periods.  Some 
patients,  however,  never  show  these  symptoms  at  any  time 
during  the  disease. 

One  of  the  fundamental  symptoms  of  the  disease  is  the 
discrepancy  or  lack  of  uniformity  between  the  emotional 
attitude  and  the  content  of  thought.  Thus,  patients  laugh 
and  cry  without  apparent  reason;  they  cheerfully  refer  to 
their  attempts  at  suicide,  and  exhibit  great  anxiety  or  out- 
bursts of  passion  upon  the  slightest  provocation.  Indeed 
this  discrepancy  between  the  ideation  and  the  emotional 
attitude  gives  one  the  impression  of  childishness.  The  whole 
conduct  shows  many  similar  incongruities;  the  discrepancy 
seen  between  the  feelings  and  the  facial  expression  is  called 
paramimia;  such  as,  weeping  on  cheerful  occasions,  and 
laughing  when  sorrow  should  prevail;  also  the  combination 
of  laughing  and  crying,  etc.  There  are  many  other  symptoms, 
as  mannerisms,  eccentricities,  and  perhaps  also  the  confu- 
sion of  speech  and  the  use  of  neologisms,  which  may  be 
explained  on  the  basis  of  a  disruption  of  the  natural  connec- 
tion between  the  processes  of  thought,  feeling,  and  will.  This 
loss  of  spontaneity  frequently  leads  to  the  idea  that  the  pa- 
tients are  being  controlled  by  the  will  of  another.  They  feel 
that  their  acts  are  not  their  own,  but  that  they  are  com- 
pelled to  do  unnatural  things.  Hence  some  patients  come  to 
believe  that  they  are  being  hypnotized. 

The  capacity  for  employment  is  seriously  impaired.  The 
patients  may  be  trained  to  do  a  certain  amount  of  routine 
work,  but  they  utterly  fail  when  given  something  new.  A 
few  patients  display  artistic  abilities,  as,  for  instance,  in 
i  Ira  wing  or  in  music,  but  their  efforts  are  characterized  by 
eccentricities.  They  may  show  some  technical  skill,  but  their 
productions  exhibit  the  absence  of  the  finer  aesthetic  feelings. 


DEMENTIA  PRECOX  229 

Physical  Symptoms.  —  Attacks,  either  of  a  syncopal  or  an 
epileptiform  nature,  are  among  the  most  important  physical 
symptoms.  These  may  occur  frequently  during  the  course 
of  the  disease  or  but  once.  They  rarely  involve  alone  single 
groups  of  muscles,  or  are  apoplectiform  in  nature  followed 
by  more  or  less  prolonged  paralyses.  Occasionally  these 
attacks  represent  the  first  symptom  of  the  disease.  They 
occur  in  about  eighteen  per  cent,  of  the  cases  and  are  twice 
as  frequent  among  women  as  among  men.  In  addition, 
hysterical  attacks  are  also  observed.  There  is  still  another 
type  of  convulsive  movement,  involving  the  muscles  of  the 
eye  and  speech,  which  is  both  characteristic  and  of  frequent 
occurrence  in  dementia  praecox.  Some  of  these  movements 
correspond  exactly  to  the  movements  of  expression;  wrin- 
kling of  the  eyebrow,  distortion  of  the  mouth,  rolling  the  eyes, 
and  those  other  facial  movements  which  are  characterized 
as  grimacing.  These  movements  remind  one  of  choreic 
movements  and  are  quite  independent  of  ideas  and  feelings. 
There  may  be  associated  with  them  smacking  of  the  lips, 
clucking  the  tongue,  sudden  grunting,  sniffing,  and  coughing. 
Furthermore,  in  the  lips  we  observe  very  rapid  rhythmical 
movements.  More  often  there  exists  a  peculiar  choreiform 
movement  of  the  mouth  which  may  be  described  as  an  athe- 
toid  ataxia. 

There  is  usually  an  increase  of  the  deep  reflexes  as  well 
as  of  the  mechanical  irritability  of  the  muscles  and  nerves. 
The  pupils  are  often  dilated,  particularly  in  conditions  of 
excitement,  and  are  occasionally  unequal.  Not  infrequently 
sensibility  to  pain  is  diminished.  Vasomotor  changes, 
as  cyanosis,  circumscribed  edema,  and  dermograph,  may 
occur  in  all  stages  of  the  disease,  but  are  most  often  met  in 
the  stuporous  states.  Excessive  perspiration  is  sometimes 
present.    The  secretion  of  saliva  is  frequently  increased. 


230  FORMS  OF  MENTAL  DISEASE 

The  heart's  activity  varies,  sometimes  being  slowed,  more 
often  accelerated,  but  also  sometimes  irregular  and  weak. 
The  menses  usually  cease  or  are  irregular.  The  body  tem- 
perature is  often  subnormal.  In  many  cases  there  has 
been  detected  a  diffuse  enlargement  of  the  glands,  which 
sometimes  undergo  atrophy  just  before  the  onset  of  the 
disease.  Exophthalmic  goitre  and  tremor  are  sometimes 
present.  Anemia  and  chlorosis  are  frequently  observed.  The 
sleep  is  apt  to  be  much  disturbed  during  the  developmental 
stage,  at  which  time  there  is  also  anorexia  and  the  patients  tend 
to  take  little  nourishment ;  but  later  in  the  course  of  the 
disease  the  taking  of  nourishment  may  vary  from  absolute 
refusal  of  food  to  extreme  gluttony.  The  body  weight 
usually  falls  at  the  onset  of  the  disease,  and  often  to  a  marked 
degree,  even  in  spite  of  the  fact  that  the  patients  are 
taking  a  sufficient  quantity  of  nourishment.  On  the  other 
hand,  the  weight  usually  rises  later  and  not  infrequently 
rapidly  and  to  a  marked  degree. 

Clinically,  the  large  group  of  cases  comprising  dementia 
praecox  is  divided  into  three  smaller  groups :  the  hebephrenic, 
the  catatonic,  and  the  paranoid,  each  of  which  differs  some- 
what in  the  grouping,  prominence,  and  course  of  the  funda- 
mental symptoms. 

Hebephrenic  Form 

The  hebephrenic  form  of  dementia  praecox  is  character- 
ized by  the  gradual  or  subacute  development  of  a  simple  more 
or  less  profound  mental  deterioration.    An  acute  onset  is  rare. 

This  form  represents  in  our  experience  fifty-eight  per  cent, 
of  the  cases  of  dementia  praecox.  The  larger  number  of  cases 
develop  under  twenty-five  years  of  age.  The  first  symptoms 
may  appear  at  the  beginning  of  puberty.  The  onset  may 
be  so  insidious  that  the  actual  date  cannot  be  placed.     Some 


DEMENTIA  PILECOX  231 

of  these  patients  do  not  even  come  under  the  care  of  the 
physician  until  years  after  the  onset  of  the  disease. 

The  hebephrenic  form  should  include  a  small  group  of 
cases  which  gradually  develop  a  simple  hypochondriacal 
dementia.  The  prominent  symptom  is  a  constantly  increas- 
ing feeling  of  physical  and  mental  incapacity,  accompanied. 
by  all  kinds  of  morbid  sensations,  which  finally  compel 
the  patients  to  desist  from  any  sort  of  activity.  At  the 
same  time  there  develops  an  emotional  indifference  and 
general  languor  without  hallucinations  or  pronounced 
delusions. 

Symptomatology.  —  Usually  the  patients  first  complain 
of  headache  and  insomnia,  which  are  soon  followed  by  a 
gradual  change  of  disposition.  They  lose  their  accustomed 
activity  and  energy,  becoming  self-absorbed,  shy,  sullen,  and 
seclusive,  or  perhaps  irritable  and  obstinate.  They  may 
be  rude  and  assertive,  or  perfectly  indifferent.  They  become 
careless  of  their  obligations,  thoughtless,  and  unbalanced. 
They  accomplish  nothing,  but  rather  sit  about  unemployed, 
apparently  brooding,  or  they  leave  their  work  to  go  to  bed, 
lying  there  for  weeks  without  evident  reason.  Others, 
instead  of  this  inaction,  exhibit  a  marked  restlessness,  and 
continuous  effort  is  impossible.  They  leave  their  work,  stroll 
about  or  travel  from  place  to  place,  especially  at  night. 
Others,  with  increased  sexual  passion,  indulge  in  illicit  and 
promiscuous  intercourse. 

During  this  period,  which  may  extend  through  several 
months,  remissions  are  common,  when  for  a  short  time  the 
patients  improve  greatly  and  may  even  appear  natural. 
This  period,  on  the  other  hand,  may  rather  be  characterized 
by  alternating  periods  of  depression  and  elation  of  increas- 
ing severity.  Women  usually  show  premonitions  of  the 
disease  during  the  menses. 


232  FORMS  OF  MENTAL  DISEASE 

Sometimes  the  onset  is  characterized  by  a  period  of  marked 
depression.  The  patients  become  apprehensive,  dejected, 
sad,  and  reserved.  They  are  troubled  with  thoughts  of 
death,  and  sometimes  suddenly  attempt  suicide,  often 
in  a  peculiar  manner.  They  are  usually  hypochondriacs, 
and  complain  of  nervousness  and  weakness;  they  search 
quack  medical  literature  and  frequently  ascribe  their  troubles 
to  former  masturbation.  There  is  also  a  mistrust  of  the 
environment  and  a  feeling  that  they  are  being  watched,  im- 
posed upon,  or  badly  treated.  But  most  striking  is  the 
emotional  indifference  with  which  the  patients  express  and 
defend  their  morbid  ideas. 

Many  cases  develop  no  further.  The  more  severe  cases 
at  this  time  begin  to  show  hallucinations,  especially  of  hear- 
ing, and  less  often  of  sight.  The  patients  are  annoyed  by 
strange  noises,  unintelligible  voices,  unfavorable  comments 
upon  their  personal  appearance;  they  hear  threats  and 
imprecations,  music  and  singing,  telephone  messages,  and 
commands  from  God.  They  may  also  see  heavenly  visions, 
crosses  on  the  wall,  dead  relatives,  frightful  accidents,  and 
deathbed  scenes.  Occasionally  they  smell  various  odors, 
especially  illuminating  gas  and  sulphur.  They  may  ex- 
perience various  hyperesthesias  which  lead  them  to  be- 
lieve that  the  head  is  double,  that  the  throat  or  nose  is 
occluded,  that  the  genitals  are  being  consumed,  or  that  the 
bowels  are  all  bound  together. 

At  the  same  time  delusions  become  a  prominent  part  of 
the  picture  and  are  mostly  of  a  depressive  character.  The 
patients  believe  themselves  guilty  of  some  crime,  accuse  them- 
selves of  being  murderers,  claim  that  they  are  lost,  are 
damned,  unfit  to  live,  have  practised  self-abuse,  and  can 
never  recover  from  its  ill  effects.  They  suspect  their  sur- 
roundings, detect  poison  in  the  food,  are  being  worked  upon 


DEMENTIA  PRECOX  233 

by  others,  their  thoughts  are  not  their  own,  friends  have 
turned  against  them  and  are  trying  to  do  them  harm,  some 
one  is  watching  them  constantly,  and  they  are  being  har- 
assed by  various  agencies.  Women  are  followed  by  men  v 
who  would  ravish  them.  Later  in  the  course  of  the  disease, 
and  occasionally  from  the  onset,  the  delusions  are  expansive; 
the  patients  then  regard  themselves  as  prominent  individuals : 
the  President,  the  Son  of  God,  the  Creator,  the  possessor  of 
the  universe.  They  converse  with  God,  are  the  Saviours  of 
men,  and  possess  all  knowledge.  Some  patients  are  con- 
trolled by  sexual  ideas,  fancying  perhaps  that  they  are  be- 
trothed to  prominent  individuals.  Men  believe  themselves 
possessed  of  many  wives,  or  regard  themselves  as  the  center 
of  attraction  for  all  women. 

These  delusions  may  be  augmented  by  numerous  fabri-v 
cations;  the  patients  claiming  that  they  have  been  Presi- 
dent for  a  century,  chief  commandant  in  various  engage- 
ments, have  been  knighted,  that  they  have  been  in  heaven, 
have  gained  possession  of  the  key  of  hell,  have  just  returned 
from  a  visit  to  Mars.  These  fabrications,  together  with  the 
delusions,  gradually  recede  to  the  background.  At  first 
they  become  less  numerous,  less  fantastic,  then  incoherent, 
and  still  more  scanty,  until  finally,  in  the  advanced  stages 
of  the  disease,  there  remain  only  incoherent  residuals  of 
former  delusions  which  may  never  be  expressed  except  when 
elicited,  or  during  excitement. 

Some  insight  into  their  condition  is  often  expressed  at  ^' 
first  by  the  patients.  They  are  conscious  that  a  change  has 
come  over  them,  and  often  complain  that  the  head  feels 
strange,  benumbed,  or  empty.  These  ideas  may  be  expressed 
in  connection  with  somatic  delusions,  when  they  will  claim 
that  the  brain  is  rotting,  the  memory  failing,  that  they  are 
different  in  every  way,  or  are  very  much  confused.    But 


234  FORMS  OF  MENTAL  DISEASE 

even  this  scanty  insight  gradually  disappears  as  the  disease 
progresses. 

In  those  forms  of  the  disease  which  develop  slowly  there 
is  at  first  neither  clouding  of  consciousness  nor  disturbance 
of  orientation.  In  the  acute  or  subacute  onset,  cloudiness 
and  general  disorientation  may  unite  in  the  clinical  picture 
with  pronounced  hallucinations  and  delusions,  anxiety 
and  restlessness,  and  incoherence  of  thought.  The  patients 
mistake  persons,  do  not  appreciate  where  they  are,  and  are 
unable  to  record  passing  events.  Physicians  are  regarded 
as  enemies  trying  to  kill  them,  working  upon  them  with 
electricity,  etc.  They  are  confined  in  a  prison  for  some  grave 
offence,  or  are  among  the  heavenly  hosts,  surrounded  by 
saints. 

The  train  of  thought  in  the  gradually  developing  cases  is 
at  first  very  little  disturbed,  the  content  of  speech  being  both 
coherent  and  relevant;  but  later  in  the  disease  and  with 
progressive  deterioration  there  develops  the  characteristic 
looseness  of  thought  and  desultoriness,  often  combined 
with  the  use  of  neologisms  and  embellishments. 

The  memory  at  first  suffers  only  moderately.  Memory  of 
earlier  life  and  the  chronological  order  of  events  is  well  re- 
tained for  a  long  time.  Some  of  the  patients  are  able  to 
tell  with  surprising  accuracy  the  exact  definitions  in  geog- 
raphy and  many  historical  events  almost  word  for  word, 
as  committed  to  memory  years  before.  But  with  the  prog- 
ress of  the  disease  there  is  an  increasing  impoverishment 
of  the  store  of  ideas.  The  impressibility  of  memory  is  re- 
tained, but  the  patients  fail  to  make  use  of  it,  because  there 
is  a  total  lack  of  interest.  Without  this  there  is  no  incen- 
tive for  observation  and  thought,  and  they  fail  to  observe 
what  is  going  on  about  them.  As  the  disease  progresses, 
there  is  increasing  limitation  of  thought.     For  this  same 


DEMENTIA  PRECOX  235 

reason  past  experiences  are  seldom  recalled,  and  so  finally 
fade  from  memory;  though  it  is  not  unusual  for  patients, 
in  reaction  to  unusual  stimulation,  to  recall  events  that 
seemed  to  have  entirely  passed  from  them. 

The  defect  in  judgment  appears  early,  develops  rapidly, 
and  becomes  profound.  This  may  not  be  evident  while 
the  patient  is  confined  at  home,  or  during  the  early  part  of 
the  residence  in  an  institution,  as  long  as  his  thought  is 
employed  with  familiar  facts,  and  his  range  for  action  limited. 
It  becomes  apparent,  however,  when  he  leaves  the  trodden 
path  and  attempts  to  adapt  himself  to  new  circumstances. 
He  is  unable  to  reason,  to  perform  mental  work,  to  recog- 
nize contradiction,  or  to  overcome  obstacles.  The  defect 
can  also  be  seen  in  his  tendency  to  formulate  and  hold  to 
senseless,  incoherent  delusions. 

In  emotional  attitude  the  most  prominent  and  permanent  Jf 
feature  is  that  of  emotional  dulness  and  indifference.  When- 
ever we  find  emotional  activity  it  is  increasingly  self-centered. 
At  first  there  is  usually  more  or  less  depression,  with  anxiety, 
peevishness,  and  often  irritability.  Exaggerated  expres- 
sions of  religious  feelings  are  apt  to  be  prominent,  the  patients 
being  devout,  praying  frequently,  reading  their  testaments, ' 
at  first  apparently  in  the  spirit  of  penitence,  but  later  be- 
cause they  are  led  by  God  or  ordained  to  do  some  special 
work.  The  sexual  feelings  very  often  play  a  prominent 
role,  particularly  in  those  who  have  been  addicted  to  the 
habit  of  masturbation.  Thought  may  center  about  sexual 
matters,  when  they  enjoy  obscene  literature,  write  long 
letters  to  acquaintances,  and  give  expression  to  their 
lascivious  feelings,  masturbate,  and  solicit  intercourse. 
Female  patients  are  more  apt  to  associate  with  their  own 
sex.  In  both  sexes  these  feelings  are  apt  to  disappear  later 
in  the  course  of  the  disease.    Later  in  the  disease  the  de- 


236  FORMS  OF  MENTAL  DISEASE 

lusions,  both  expansive  and  hypochondriacal,  are  expressed 
without  display  of  emotion.  Patients  fail  to  express  emotion 
at  the  loss  of  friends,  at  the  visits  of  relatives,  or  at  an  un- 
usual supply  of  food,  fruit,  or  candies.  They  live  a  very 
empty  life,  devoid  of  any  cares  or  anxieties,  and  without 
thought  for  the  future. 

In  conduct  and  behavior,  the  most  characteristic  symp- 
tom is  that  of  childish  silliness  and  senseless  laughter.  The 
voluntary  activity  is  inconsistent  and  lacks  independence. 
At  one  moment  patients  are  increasingly  headstrong,  at  the 
next  as  supremely  tractable.  They  neglect  their  personal  ap- 
pearance, perform  all  sorts  of  outlandish  and  foolish  deeds, 
such  as  prowling  about  all  night,  setting  fire  to  buildings, 
throwing  stones  to  break  windows,  and  travelling  about  with- 
out evident  purpose.  They  may  even  run  away  and  secrete 
themselves,  or  as  unexpectedly  demand  some  one  in  marriage, 
forget  their  obligations,  and  finally  are  completely  inca- 
pable of  continued  and  comprehensive  employment.  A 
young  man  was  found  throwing  stones  into  trees  because  the 
voices  of  evil  spirits  annoyed  him.  A  student  ran  from  his 
mates  to  a  graveyard  and  covered  himself  with  leaves  in 
order  to  obtain  aid  in  committing  his  ivy  oration.  A  girl 
of  fourteen  attempted  to  stab  her  lover,  believing  him  to  be 
unfaithful.  A  young  married  woman  solicited  intercourse 
among  gentlemen  friends,  even  bringing  them  to  her  home 
for  that  purpose  in  the  presence  of  her  husband  and  children. 
The  patients  are  very  often  seen  to  converse  with  them- 
selves, sometimes  aloud,  while  associated  with  this  there  is 
almost  always  silly  laughter.  This  silly  laughter  is  a  very 
prominent  and  characteristic  symptom.  It  is  unrestrained, 
appears  on  all  occasions  without  the  least  provocation,  and 
is  altogether  without  emotional  significance.  Besides  these 
actions,  mannerisms,  such  as  peculiarities  of  speech  and 


DEMENTIA  PILECOX  237 

movements,  eating  and  walking,  are  often  present.  A  few 
of  the  mannerisms  characteristic  of  the  catatonic  may  pre- 
vail: echolalia,  echopraxia,  stereotyped  expressions  and 
movements. 

The  speech  presents  peculiarities  indicative  of  looseness 
of  thought  and  confusion  of  ideas.  Their  remarks  may 
be  artificial,  containing  many  stilted  phrases,  stale  witti- 
cisms, foreign  expressions,  and  obsolete  words.  The  in- 
coherence of  thought  becomes  most  evident  in  their  long 
drawn  out  sentences,  in  which  there  is  total  disregard  for 
grammatical  structure.  The  structure  changes  frequently, 
and  there  are  many  senseless  interpolations.  All  this  be- 
comes even  more  apparent  in  their  letters,  which  are  ver- 
bose with  frequent  repetitions,  while  the  handwriting  is 
characterized  by  a  marked  lack  or  a  superfluity  of  punctua- 
tion marks,  shading  of  letters,  and  copious  underlining. 

Physical  Symptoms.  —  During  the  onset  of  the  disease 
the  condition  of  general  nutrition  suffers.  There  is  a  loss 
of  weight,  and  some  patients  even  become  emaciated.  The 
appetite  is  poor.  Patients  eat  sparingly  or  not  at  all,  re- 
strained by  suspicion  and  fear,  or  because  they  are  so  directed 
by  God.  The  sleep  also  is  much  disturbed,  both  by  anxiety 
and  distressing  dreams.  The  pupils  are  occasionally  dilated. 
The  tendon  reflexes  may  be  exaggerated,  and  vasomotor 
disturbances  may  be  present.  The  skin  loses  its  normal 
healthy  appearance,  becoming  dry  and  flaccid.  The  menses 
cease  or  become  irregular.  Later  in  the  course  of  the  disease 
the  appetite  returns  and  often  becomes  excessive.  At  this 
time  the  weight  often  rises  rapidly,  and  the  emaciated  con- 
dition is  frequently  replaced  by  great  corpulence.  The 
menses  also  reappear  and  remain  normal,  and  the  evidences 
of  muscular  and  nervous  irritability  disappear. 

Course. — The  course  of  the  disease  in  the  hebephrenic 


238  FORMS  OF  MENTAL  DISEASE 

form  is  characterized  by  all  sorts  of  variations.  Suitable 
treatment  during  the  active  stages  at  the  onset  usually 
produces  some  improvement.  But  there  develops  later 
a  condition  of  uniform  dementia,  which  may  be  permanent, 
or  interrupted  by  repeated  exacerbations.  Occasionally 
there  develop  conditions  of  pronounced  excitement  with 
mischievousness,  talkativeness,  clownish  behavior,  laughing, 
giggling,  a  tendency  to  sexual  acts,  and  senseless  wandering 
about.  In  other  cases  there  develop  profound  clouding, 
with  impulsiveness,  greater  incoherence  of  thought,  dancing, 
smearing,  destructiveness,  and  assaults.  These  conditions 
are  usually  of  short  duration.  They  may  recur  suddenly 
and  without  warning.  The  degree  of  mental  defect  increases 
from  year  to  year,  more  especially  following  the  transitory 
periods  of  excitement. 

Of  the  cases  that  are  admitted  to  insane  institutions, 
about  seventy-five  per  cent,  reach  a  profound  degree  of  deteri- 
oration. These  patients  are  dull,  indolent,  apathetic, 
anergic,  sluggish,  and  fail  to  apprehend  the  surroundings. 
They  remain  seated  for  hours  wherever  placed,  are  incapable 
of  caring  for  themselves,  are  untidy,  have  to  be  dressed  and 
undressed,  and  led  to  meals.  At  table  they  are  slovenly, 
spattering  and  smearing  themselves  with  food.  They  give 
but  little  evidence  of  voluntary  activity.  They  seldom  speak, 
are  unproductive  and  mute;  occasionally  they  may  be  seen 
to  laugh  sillily  or  repeat  to  themselves  some  unintelligible 
word  or  syllable. 

Their  attention  is  attracted  with  difficulty  and  held  only 
for  a  short  time.  External  objects  usually  fail  to  make  an 
impression  upon  them.  Questions  are  apparently  uncom- 
prehended,  seldom  exciting  intelligible  answers.  These 
are  usually  monosyllabic  and  irrelevant.  Simple  directions, 
however,  may  be  correctly  carried  out.     Relatives  and  ac- 


DEMENTIA  PILECOX  239 

quaintances  may  not  be  recognized.  Bits  of  former  knowl- 
edge are  retained  in  many  cases  for  a  long  time,  such  as 
historical  and  geographical  facts  and  the  ability  to  solve  prob- 
lems in  arithmetic.  In  this  respect  the  patients  often  sur- 
prise one.  One  of  my  patients  was  able  to  name  the  islands 
of  the  Pacific  and  give  the  names  of  their  sovereigns. 
Another,  who  for  two  years  had  been  mute,  unable  to  care 
for  himself,  untidy,  sitting  through  the  day  with  bowed 
head,  entirely  unmindful  of  his  surroundings,  recognized 
a  college  mate,  straightened  up  with  an  air  of  dignity,  and 
laughed  at  some  college  jokes.  In  the  course  of  time  even 
such  relics  of  former  mental  activity  disappear,  and  we  have 
nothing  left  but  the  unproductive  vegetative  organism. 
A  few  patients  retain  some  remnants  of  mental  activity,  but 
they  are  quite  unbalanced,  silly,  and  present  the  residuals 
of  hallucinations  and  delusions.  Instead  of  the  extreme 
stupidity  and  indolence  some  patients  continue  restless  and 
talkative,  producing  an  incoherent  babble  with  silly  laughter. 
During  the  periods  of  transitory  excitement  these  patients 
are  very  apt  to  be  aggressive,  breaking  windows  and  attack- 
ing fellow-patients,  to  masturbate  shamelessly,  pull  out  their 
hair,  and  frequently  show  homicidal  tendencies.  Usually 
it  requires  several  years  before  the  patients  reach  this  stage 
of  dementia.  In  cases  with  an  acute  onset  it  may  appear 
within  a  year. 

In  about  seventeen  per  cent,  of  the  cases  the  degree  of  de-- 
terioration  is  not  as  far  advanced.  These  patients,  after  the 
subsidence  of  the  more  acute  symptoms,  show  a  certain 
amount  of  mental  activity  and  are  capable  of  some  employ- 
ment under  supervision.  They  are  oriented  and  have  a 
certain  amount  of  insight  into  their  mental  incapacity,  but 
lack  mental  energy  and  the  power  of  application.  They 
have  little  interest  in  the  surroundings,  no  care  for  their 


\s 


240  FORMS  OF  MENTAL  DISEASE 

own  livelihood,  and  no  thought  for  the  future,  but  are  con- 
tented to  live  and  be  cared  for.  In  conduct  they  are  apt 
to  present  many  mannerisms. 

The  judgment  is  weak  and  memory  defective.  Impor- 
tant events  may  be  retained,  together  with  school  knowl- 
edge, but  memory  for  events  subsequent  to  the  onset  of  the 
psychosis  is  very  poor,  while  they  are  quite  incapable  of 
acquiring  additional  knowledge.  The  hallucinations  and 
delusions  of  the  various  stages  of  the  disease  for  the  most 
part  entirely  disappear.  While  retained  in  a  few  cases,  they 
are  of  little  importance  to  the  patients,  rarely  influencing 
their  behavior.  As  in  the  other  grades  of  dementia,  so  here, 
there  is  a  tendency  for  the  deterioration  to  increase  as  the 
patients  advance  in  age.  This  is  especially  noticeable  fol- 
lowing short  periods  of  excitement,  which  are  apt  to  be  co- 
incident with  menstruation.  At  these  times  the  patients 
show  motor  restlessness,  with  great  irritability  and  some- 
times violence,  with  a  reappearance  of  former  delusions  and 
hallucinations,  talkativeness,  silly  behavior,  and  incapacity 
for  employment.  The  delusions  are  more  apt  to  be  expan- 
sive, changeable,  and  incoherent,  but  at  times  there  may 
be  verbigeration  and  repetition  of  single  phrases.  The 
actions  are  usually  purposeless. 

A  few  of  these  cases  leave  the  institution  apparently  recov- 
ered, but  upon  reaching  home  the  patients  fail  to  employ 
themselves  profitably.  They  spend  much  time  in  reading, 
evolving  impractical  schemes,  and  pondering  over  abstract 
and  useless  questions.  Or,  if  employed,  they  show  a  lack 
of  interest,  are  unbalanced,  and  unable  to  advance  in  their 
profession  or  occupation.  Later  their  field  of  thought  be- 
comes more  circumscribed  and  their  relations  with  the 
outside  world  correspondingly  meagre.  They  become  se- 
clusive  and  so  much  disinterested  in  intellectual  work  that 


DEMENTIA  PRECOX  241 

they  pass  their  time  in  purely  machine-like  action,  engaged 
in  gardening  or  transcribing. 

Finally  in  about  eight  per  cent,  of  the  cases  the  symptoms 
of  the  disease  entirely  disappear,  leaving  the  patients  apparently 
in  their  normal  condition.  Not  all  of  these  cases  should  be 
regarded  as  perfect  recoveries,  because  in  some  instances  there 
have  been  recurrences  in  later  life,  followed  by  deterioration. 
In  still  other  cases  there  has  been  a  stunting  of  mental  de- 
velopment. The  patients  have  been  unable  to  realize  their 
ambition.  Young  men  and  women  whose  academic  or 
collegiate  courses  have  been  interrupted  by  the  psychosis 
find  themselves  unable  to  enter  into  active  business  or  pro- 
fessional life.  These  patients  are  able  to  care  for  a  farm 
or  a  small  business  where  there  is  little  demand  for  in- 
tellectual work.  In  this  way  we  lose  sight  of  the  mental 
shipwreck  following  dementia  praecox,  because  enough  men- 
tal capacity  is  retained  to  permit  them  to  maintain  the 
battle  of  life  in  their  chosen  narrow  field. 

Catatonic  Form  (Catatonia) 

The  catatonic  form  of  dementia  prsecox  is  especially 
characterized  by  stuporous  states  with  negativism,  hyper- 
suggestibility,  and  uniform  muscular  tension;  excited  states 
with  stereotypy  and  impulsiveness;  leading  in  most  cases,  with 
or  without  remissions,  to  mental  deterioration.  This  form 
comprises  in  our  experience  about  eighteen  per  cent,  of 
the  entire  group  of  dementia  praecox. 

Pathological  Anatomy.  —  Alzheimer,  in  fatal  cases  of 
acute  delirium  which  he  believed  belonged  to  catatonia, 
has  described  profound  changes  in  the  cortical  neurones 
of  the  deeper  layers.  The  nucleus  was  much  swollen,  its 
membrane  wrinkled,  and  the  cell  body  shrunken,  with  a 
tendency  to  disappear.    In  the  glia  there  was  an  increase  of 


242  FORMS  OF  MENTAL  DISEASE 

fibres  which  fastened  about  the  cell  in  a  peculiar  manner. 
Nissl,  in  all  prolonged  cases  of  catatonia,  has  demonstrated 
extensive  changes  in  the  cells,  which  vary  considerably  in 
degree  as  well  as  kind.  Even  in  cases  where  there  appeared 
to  be  no  atrophy  in  the  cortex,  he  found  a  number  of  cells 
which  had  undergone  degeneration.  In  the  deeper  layers 
of  the  cortex  very  large  glia  cells  were  found  which  normally 
appear  only  in  the  outer  layers.  Elsewhere  the  cortex 
contained  glia  cells  with  slightly  stained  cell  bodies  and 
large  pale  nuclei  with  small  vesicles,  which  were  in  close 
approximation  to  the  degenerated  nerve  cells,  not  only  at 
the  base  of  the  cell  body,  like  the  satellite  cells,  but  also 
surrounding  it.  This  pathological  lesion  and  the  type  of 
glia  cells  are  not  peculiar  to  catatonia,  but  they  are  found  to 
a  striking  degree  in  the  deeper  cortical  layers  in  this  disease. 
Symptomatology.  —  The  onset  of  the  psychosis  is  usually 
subacute,  with  a  condition  of  mental  depression  quite 
similar  to  that  observed  in  the  hebephrenic  form.  The 
patients  for  several  weeks  before  the  onset  may  have  ap- 
peared unusually  quiet,  serious,  or  even  anxious,  complain- 
ing of  difficulty  of  thought,  of  headache,  or  of  peculiar 
sensations  in  the  head.  Besides  this,  they  may  have  suffered 
from  insomnia  and  loss  of  appetite,  and  have  left  their  work 
because  of  nervousness  and  general  ill  health.  Gradually 
the  patients  show  great  anxiety,  and  express  fear  of  impend- 
ing danger.  Their  religious  emotions  become  more  promi- 
nent, and  hallucinations  and  delusions  appear.  A  voice 
from  heaven  directs  them  to  do  all  sorts  of  things.  One 
patient  is  commanded  to  spit  to  the  right,  and  another  to 
convert  sinners.  There  is  a  vision  of  Christ  on  the  cross, 
the  Virgin  Mary  appears,  faces  are  seen  at  the  window  and 
pictures  on  the  wall,  spirits  hover  about,  some  one  speaks 
from  the  radiator,  and  there  is  music  in  the  next  room.    They 


DEMENTIA  PILECOX  243 

hear  their  children  cry  for  help.  Some  one  calls  their  name, 
and  they  hear  their  own  thoughts.  Little  birds  speak  to 
them.  Specks  of  poison  are  detected  in  the  food;  sulphur 
fumes  are  set  free  about  them;  some  one  pulls  at  their  hair, 
injects  water  into  their  limbs,  or  applies  electricity  to  them. 

The  delusions  are  usually  of  a  religious  nature,  are  inco- 
herent and  changeable  from  day  to  day.  The  patient  is 
persecuted  for  his  sins,  a  priest  has  come  to  anoint  him  be- 
fore he  dies.  God  has  transferred  him  to  heaven,  where  he 
is  surrounded  by  angels.  He  no  longer  needs  food,  as 
Christ  has  forbidden  him  to  eat.  He  is  eternally  lost, 
is  possessed  of  the  devil,  has  caused  destruction  of  the  whole 
world;  all  are  dead;  he  is  surrounded  by  spirits,  his  children 
are  lost,  the  wife  false,  his  body  has  been  transformed  into 
mules'  hoofs,  his  hands  into,  claws,  his  brain  has  been  drawn 
off,  and  while  hung  to  a  cross,  his  limbs  and  body  have  run 
away  like  molten  metal.  The  delusions  may  later  become 
expansive,  though  they  are  occasionally  expansive  from  the 
onset.  The  patient  then  believes  himself  transformed  into 
Christ,  has  all  power,  can  create  worlds,  has  lived  for  thou- 
sands of  years,  possesses  all  knowledge,  can  cast  out  evil 
spirits,  is  a  millionaire,  owns  railroads,  etc. 

During  the  earlier  stages  of  the  disease  some  peculiarities 
of  movement  and  action  appear,  particularly  constraint, 
which  may  increase  to  a  state  of  muscular  tension.  The 
patients  assume  constrained  attitudes,  holding  the  arms 
in  awkward  positions,  as  in  the  form  of  a  cross,  etc.,  stand- 
ing or  walking  in  an  awkward  manner,  all  of  which  may 
be  symbolical  of  their  ideas.  One  patient  stood  for  hours 
with  hands  behind  him  and  head  thrown  back,  staring 
fixedly  at  the  ceiling,  and  another  lay  in  the  form  of  a  cross 
upon  the  floor.  In  some  there  is  a  tendency  to  execute 
rhythmical  movements,  such  as  rolling  the  head  from  side 


244  FORMS  OF  MENTAL  DISEASE 

to  side,  or  expectorating  at  stated  intervals  in  a  fixed  direc- 
tion. 

In  this  period  of  depression  the  consciousness  is  somewhat 
clouded,  orientation  is  slightly  disturbed,  and  the  patients 
do  not  apprehend  clearly  what  goes  on  about  them.  They 
may  know  that  they  are  at  home  or  in  an  institution,  but  they 
fail  to  appreciate  the  mental  condition  of  their  fellow- 
patients,  mistake  those  about  them  for  friends  and  acquaint- 
ances, or  they  claim  that  everything  is  changed  and  that 
they  cannot  understand  the  mystery  of  it  all.  Some  believe 
themselves  translated  to  heaven,  that  they  are  in  a  cloister, 
or  in  a  foreign  city. 

Thought  is  loose  and  somewhat  desultory  and  reasoning 
is  difficult.  The  memory  for  remote  events  is  well  retained 
and  impressibility  is  surprisingly  good.  Although  the 
physician  may  be  mistaken  for  Christ  or  some  one  else,  he 
is  always  remembered.  Occasionally  genuine  falsifications  of 
memory  are  seen. 

The  emotional  attitude  is  at  first  quite  in  accord  with  the 
delusions  and  hallucinations.  The  patients  are  sad,  de- 
jected, anxious,  complaining,  irritable,  distrustful,  and 
sometimes  threatening ;  when  interfered  with,  they  are  very 
apt  to  become  violent.  Occasionally  sexual  excitement 
leads  to  masturbation  and  obscenity.  Later  they  lose  their 
early  anxiety,  become  indifferent  or  contented  with  their 
environment,  and  the  delusions  are  expressed  without 
emotion.  Some  patients  are  even  cheerful  and  happy,  or 
ecstatic. 

The  disturbances  in  conduct  and  actions  are  very  striking. 
The  patients  cease  work  and  lie  listlessly  about;  they  laugh 
without  apparent  reason,  indulge  in  excesses,  neglect  them- 
selves, and  sometimes  utter  threats.  Many  patients  pray 
constantly  and  devote  much  time  to  attending  church  ser- 


DEMENTIA  PRECOX  245 

vices;  not  a  few  attempt  suicide  or  assault  friends  or  rela- 
tives without  reason. 

Following  this  preliminary  period  of  the  disease,  which 
in  most  respects  is  quite  similar  to  that  in  the  hebephrenic 
form7  the  more  characteristic  catatonic  symptoms  appear; 
namely,  the  catatonic  stupor  and  the  catatonic  excitement. 
In  at  least  one-third  of  the  cases  these  symptoms  appear  at 
the  very  onset  of  the  disease. 

The  catatonic  stupor  is  chiefly  controlled  by  the  symp- 
toms negativism  and  automatism.  Negativism  often  oc- 
curs first  in  the  form  of  mutism,  when  the  patients  refuse 
to  speak.  They  begin  by  speaking  low,  breaking  off  in  the 
midst  of  a  sentence  or  answering  in  monosyllables,  then 
they  may  whisper  unintelligibly,  and  finally  refuse  to  speak 
altogether.  Some  patients  in  this  condition  may  be  per- 
suaded to  write  or  sing  answers  to  questions.  When  ad- 
dressed they  remain  with  closed  eyes  or  staring  fixedly  at 
some  distant  object,  apparently  paying  absolutely  no  atten- 
tion to  the  physician.  Even  shaking  patients,  pinching 
them,  or  prodding  them  with  a  needle  fails  to  elicit  a  re- 
sponse, except  when  in  pain;  then  the  lips  may  become 
more  closely  pressed  together  or  the  patients  may  move 
away  indifferently. 

Further  evidence  of  negativism  is  seen  in  the  obstinate 
and  persistent  resistance  which  the  patients  make  to  every 
attempt  at  handling  them.  They  resist  being  put  to  bed 
and  being  taken  out,  dressing  or  undressing,  moving  for- 
ward or  backward,  opening  the  eyes  or  closing  them.  The 
active  resistance  is  well  demonstrated  by  suddenly  with- 
drawing the  hand  which  has  been  placed  against  the  patient's 
forehead,  when  it  springs  forward  with  a  jerk.  The  physical 
origin  of  this  resistance  becomes  more  apparent  in  those 
cases  in  which  the  desired  action  is  only  elicited  by  com- 


246  FORMS  OF  MENTAL  DISEASE 

manding  the  patient  contrariwise.  One  may  get  a  patient 
to  open  his  eyes  by  urging  him  to  close  them  tightly,  to  lower 
the  hand  by  telling  him  to  lift  it,  etc. 

Even  the  most  natural  impulses  are  resisted,  as  seen  in 
their  stubborn  refusal  to  wear  shoes  or  stockings,  in  the 
tendency  to  sit  on  the  floor  rather  than  in  a  chair,  or  to  sleep 
under  the  bed  and  not  in  it,  and  go  to  the  closet  by  the 
longest  route.  They  prefer  to  eat  another's  food,  and  some 
persist  in  crawling  into  the  beds  of  others.  Finally  the  re- 
fusal of  food  and  the  retention  of  urine  and  feces  are  evidences 
of  more  extreme  negativism.  The  former  may  last  for 
months.  The  absence  of  food  for  a  week  will  not  overcome 
this  disinclination  to  take  food  voluntarily.  It  is  not  un- 
usual for  this  form  of  negativism,  as  well  as  the  others,  to 
appear  and  disappear  suddenly.  Sometimes  the  patients 
will  begin  to  eat  if  transferred  to  another  ward,  or  will  re- 
main in  bed  if  given  a  different  bed.  The  urine  and  feces 
may  be  retained  until  there  is  marked  distention.  In  a 
few  cases  it  is  necessary  to  overcome  this  by  catheterization 
and  enemata. 

There  is  usually  associated  with  negativism  an  unusual 
uniformity  of  the  muscular  tension  which  is  exhibited 
in  several  ways,  especially  in  the  extraordinary  uniformity 
of  position  maintained  by  the  body  or  its  various  parts.  In 
this  condition  patients  maintain  the  same  position  for  weeks 
and  even  months.  The  usual  position  is  on  the  back,  with 
limbs  stretched  out,  the  eyelids  closed  with  the  eyeballs 
rolled  upward  and  inward,  or  with  the  eyes  open  staring 
fixedly  in  the  distance,  the  face  mask-like  with  lips  slightly 
closed  and  at  the  same  time  protruded.  The  hands  are 
very  often  clenched,  as  if  there  were  permanent  contractures, 
the  fingers  producing  pressure  marks  on  the  palms.  Plates 
1  and  2  represent  two  stuporous  catatonic  patients.     The 


Plate  1.    Muscular  tension  in  catatonic  stupor. 


DEMENTIA  PRECOX  247 

boy  rigidly  maintained  this  uncomfortable  position  for 
weeks,  with  his  head  thrown  far  backward,  eyes  tightly 
closed,  and  face  mask-like  with  protruded  lips.  While  in 
this  condition  he  required  daily  feeding  by  nasal  tube.  The 
woman  maintained  this  same  position  for  over  four  years 
without  a  known  voluntary  attempt  to  change  it.  The 
body  and  head  are  slightly  bent  forward  with  the  eyes  staring 
directly  in  front  of  her,  the  lips  protruded,  the  arms  flexed, 
and  hands  so  tightly  clenched  that  cotton  must  be  placed 
in  the  fists  to  prevent  pressure  sores.  While  in  bed  she  lies 
straight  upon  the  back  with  knees  strongly  adducted  and 
arms  drawn  closely  to  the  chest,  but  with  the  fists  in  the 
same  constrained  position.  During  this  long  period  it  has 
been  necessary  to  feed  her  by  spoon.  Others  lie  rolled  up 
like  a  ball,  with  head  thrown  forward  and  knees  drawn  to 
the  chin.  In  the  extreme  condition  these  patients  may 
be  rolled  about  or  lifted  and  laid  across  some  object  without 
movement,  as  rigid  as  a  piece  of  wood.  Muscular  tension  is 
not  evenly  distributed,  but  is  most  frequently  seen  in  the 
hands,  arms,  face,  and  lower  limbs.  The  gait  is  often  in- 
fluenced by  this  condition,  some  patients  being  unable  to 
move  at  all,  falling  rigidly  to  the  floor  when  raised  to  their 
feet;  others  walk  stiffly,  with  unbent  knees,  on  tiptoes,  or 
on  the  outer  side  of  the  feet  with  the  body  bent  forward  or 
backward.  The  movements  are  usually  slow  and  constrained. 
Sometimes  the  counter  impulses  seem  to  be  suddenly  over- 
come and  the  movements  become  rapid. 

The  hypersuggestibility  is  seen  especially  in  catalepsy,  and 
less  frequently  in  echopraxia  and  echolalia,  the  latter  of 
which  are  usually  of  short  duration.  In  the  echolalia  and 
echopraxia  the  patients  simply  repeat  in  a  wholly  mechan- 
ical and  monotonous  manner  what  they  may  happen  to 
hear  or  see  done  in  their  presence.    They  imitate  or  mimic 


v 


i/ 


248  FORMS  OF  MENTAL  DISEASE 

every  act  of  some  person  in  their  environment.  Questions 
asked  are  only  repeated.  The  condition  of  catalepsy  is 
well  seen  in  the  patient  depicted  on  Plate  3.  She  had 
been  placed  in  this  awkward  and  very  uncomfortable  posi- 
tion, which  she  maintained  until  relieved.  The  feet  are 
separated,  drawn  backward,  and  elevated  so  that  the  toes 
barely  touch  the  floor;  the  arms  are  elevated  and  drawn 
backward ;  and  the  head  is  extended  as  far  as  possible. 

These  disturbances  of  the  will  become  evident  when  one 
requests  the  patient  to  protrude  his  tongue,  in  order  that 
it  may  be  punctured  with  a  needle.  Although  he  sees  the 
needle  and  comprehends  that  you  are  threatening  him  with 
it,  yet  upon  request  he  shoots  out  his  tongue  without  hesi- 
tation, and  will  repeat  the  experiment  as  often  as  you 
command  him.  He  frowns  when  pricked,  but  is  unable  to 
suppress  the  impulse  released  by  the  command. 

These  apparently  opposite  states  of  negativism  and  hyper- 
suggestibility  may  pass  directly  from  one  into  another 
during  the  stage  of  stupor.  Absolute  silence  suddenly 
gives  way  to  loud  and  unrestrained  shouting  or  to  incessant 
prattle;  the  patients  awake  from  the  stupor  and  talk  as  if 
nothing  had  happened,  and  again  in  a  few  hours  relapse  into 
their  former  stuporous  state.  Sometimes  these  changes 
can  be  brought  about  by  mere  suggestion.  Such  changes 
are  quite  characteristic  of  catatonia. 

Interrupting  the  stupor  or  following  it,  and  sometimes 
even  preceding  it,  we  have  the  catatonic  excitement,  which 
is  characterized  by  impulsive  actions  and  stereotyped  move- 
ments. The  condition  of  excitement  usually  develops 
rapidly  and  often  follows  the  initial  condition  of  depres- 
sion already  described.  The  patients  suddenly  leap  from 
bed,  tear  their  clothing,  break  the  furniture,  race  about  the 
room,  shouting  or  singing,  throw  themselves  upon  the  floor, 


Plate  2.     Muscular  tension  in  catatonic  stupor. 


DEMENTIA  PRECOX  249 

rotating  the  head  from  side  to  side,  breathing  rapidly, 
churning  saliva  in  the  mouth,  or  making  a  peculiar  blowing 
sound.  They  may  run  about  the  house  for  hours  at  a  time, 
striking  the  bed  or  the  wall  in  a  certain  place.  While  lying 
in  bed  the  body  may  be  swayed  regularly  back  and  forth, 
or  the  bed  tapped  at  a  certain  place  at  regular  intervals 
In  walking  they  are  apt  to  assume  peculiar  attitudes. 
One  patient  stood  for  hours  against  the  wall  in  the  form  of 
a  cross,  repeating,  "  the  Father,  the  Son,  and  the  Holy 
Ghost";  another,  holding  his  nose  tightly  with  his  hands, 
uttered  a  monotonous  grunt  for  hours  at  a  time.  Mingled 
with  these  movements  are  seen  numerous  impulsive  move- 
ments when  the  patients  jump  about  from  one  object  to 
another,  pounding  themselves,  knocking  their  heads  against 
the  wall,  wringing  their  hands,  jumping  up  and  down  on 
the  bed,  and  stamping  on  the  floor.  All  of  these  most  varied 
movements  are  carried  out  with  great  strength  and  reckless- 
ness, without  regard  for  the  surroundings  or  themselves, 
and  are  for  the  most  part  purposeless  and  impulsive.  In  the 
midst  of  their  ceaseless  tramping  about  the  room  they  may 
suddenly  grab  at  the  clothing  of  the  physician  or  assault  a 
fellow-patient.  During  this  excitement  the  patients  are 
very  untidy  and  filthy,  expectorating  in  the  food,  smearing 
with  feces  and  food,  urinating  in  the  bed  and  clothing, 
and  even  washing  themselves  with  urine.  Sexual  excite- 
ment very  often  accompanies  this  condition. 

Mannerisms  in  facial  expression  and  speech  are  especially 
characteristic  of  these  catatonic  states.  Accompanying 
speech  there  is  a  peculiar  gesticulation,  winking  of  the  eyes, 
senseless  shaking  and  nodding  of  the  head,  and  drawing  of 
the  muscles  of  expression.  The  voice  assumes  a  peculiar 
intonation  or  may  quiver.  The  manner  of  speech  may  be 
scanning,  rhythmical,  or  explosive.    The  content  of  speech 


v 


250  FORMS  OF  MENTAL  DISEASE 

is  often  quite  characteristic,  consisting  of  a  series  of  sense- 
less syllables  repeated  in  a  fixed  measure  or  rhyme.  Words 
or  short  sentences  are  likewise  repeated;  the  words  may 
be  clipped  or  the  last  syllable  drawn  out.  Usually  these 
expressions  bear  no  relation  to  the  trend  of  conversation. 
One  patient,  when  asked  how  he  felt,  repeated  for  three 
minutes,  "  I  see  you,  I  see  you." 

Another  common  disturbance  is  the  inconsequential 
answering  of  questions.  The  patients  react  to  every 
question  but  not  according  to  its  sense.  The  answers 
are  generally  irrelevant,  though  occasionally  they  have 
more  or  less  remote  reference  to  the  question  as  though 
the  desired  information  was  avoided.  The  following  is  an 
example :  — 

How  do  you  feel  this  morning?  "  It  is  a  fine  morning." 
Did  you  sleep  well?  "  It  was  a  cold  night."  Who  is  this 
lady  (indicating  a  nurse)  ?  "  The  lady  with  the  black 
clothes  "  (dressed  in  white).  What  is  her  name?  "  Clara 
Swanson"  (the  name  of  a  fellow-patient).  How  many 
windows  are  there  in  the  room?  "Three"  (four).  How 
many  of  us  are  there  in  the  room ?  "  Three  "  (four).  What 
day  of  the  month  is  it?  "September  35"  (October  5). 
How  much  money  have  I  here?  "  Two  dimes  "  (a  quarter). 
How  much  now?  "Two  dollar  bills"  (one  dollar  bill), 
etc. 

Such  responses  in  a  medico-legal  case  would  be  very  sug- 
gestive of  simulation,  but  their  apparently  close  relation- 
ship to  negativistic  states  should  in  such  cases  lead  one  to 
search  for  other  negativistic  signs. 

In  their  voluntary  speech  genuine  desultoriness  is  often 
seen  (see  example,  p.  40).  Neologisms,  the  repetition  of 
senseless  expressions,  and  the  use  of  sentences  that  are  wholly 
devoid  of  connection  are  frequent,  while  at  the  same  time 


Plate  3.     Cerea  flexibilitas  in  catatonic  stupor. 


Fig.  1.  —  Catatonic  writing  showing  verbigeration. 


DEMENTIA  PRECOX  251 

the  patient  affects  lisping  and  grunting,  or  speaks  in  a  falsetto 
voice.  Agrammatism  is  sometimes  present,  in  that  the 
patients  seem  unable  to  construct  sentences  and  use  only 
infinitives  in  speaking. 

Verbigeration  is  also  a  frequent  symptom  in  the  catatonic 
excitement  as  well  as  in  the  stupor.  It  consists  in  the  use 
of  many  motor  expressions,  the  tendency  to  stereotypy, 
and  the  repetition  of  similar  impulses.  The  patients  will 
repeat  for  hours  and  even  days  at  a  time  senseless  expres- 
sions, or  single  syllables,  usually  in  the  same  monotonous 
manner,  though  sometimes  modified  by  shrieking  or  sing- 
ing them.  Verbigeration  is  especially  noticeable  in  the 
voluntary  writings  of  the  patient,  which  are  made  still  more 
striking  by  excessive  underfilling,  shading,  and  addition  of 
symbols. 

Catatonic  stupor  often  passes  abruptly  into  catatonic 
excitement  and  vice  versa.  The  excitement  is  more  apt  t6 
precede.  Sometimes  one  state  replaces  the  other  for  only 
a  few  minutes  or  hours.  The  degree  of  stupor  or  excitement 
varies  considerably  in  individual  cases. 

During  the  stage  of  catatonic  stupor  and  excitement,  the 
consciousness  is  somewhat  clouded,  but  the  patients  seldom 
lose  their  orientation  completely.  In  spite  of  the  fact  that 
they  seem  quite  unconscious  of  and  unable  to  comprehend 
their  surroundings,  the  patients  will  awake  from  a  condition 
of  stupor  and  give  the  names  of  those  about  them,  telling 
the  day  and  the  month,  and  showing  surprising  knowledge 
of  what  has  happened  within  their  limited  range  of  obser- 
vation. 

Partial  insight  into  the  conditions  of  stupor  and  excite- 
ment is  frequently  expressed  by  the  patients,  when  they 
refer  to  their  peculiar  acts  as  foolish,  but  say  they  could  not 
help  doing  them.    Others  say  that  they  felt  compelled  to 


252  FORMS  OF  MENTAL  DISEASE 

do  what  was  requested,  that  they  could  not  remain  quiet 
until  it  was  done,  or  that  they  are  commanded  by  God;  but 
whatever  the  explanation,  it  is  apparent  that  their  peculiar 
acts  are  distinctly  impulsive  and  not  the  outcome  of  reason- 
ing. 

The  emotional  attitude  during  these  distinctly  catatonic 
states  exhibits  no  striking  disorder.  They  are  mostly  in- 
different as  to  their  delusions  and  conduct.  Threats  make 
no  impression  upon  them.  Provided  negativistic  symp- 
toms are  not  present,  they  will  not  wince  when  threatened 
with  a  burning  match  or  an  open  knife,  and  will  not  even 
wink  when  the  eye  is  approached  with  a  needle.  Occasion- 
ally there  are  observed  changeable  states  of  childish  petu- 
lancy,  irritability,  or  silly  elation  and  ecstasy. 

Physical  Symptoms.  —  In  some  cases  elevated  tempera- 
ture, varying  between  one  hundred  and  one  hundred  and  two 
degrees  during  the  acute  onset  of  the  symptoms,  may  persist 
for  two  or  more  weeks.  Cyanosis,  dermography,  and  local- 
ized sweating  often  occur.  Convulsive  attacks  are  also 
encountered  in  a  few  cases,  mostly  at  the  onset.  There 
is  loss  of  weight  during  the  stage  of  depression.  This 
becomes  more  prominent  during  the  stupor  and  may  reach 
extreme  emaciation  in  spite  of  forced  feeding.  Later, 
sometimes  beginning  during  stupor,  the  weight  rises. 
During  the  stage  of  deterioration  the  patients  usually  be- 
come quite  fleshy.  During  stupor  the  skin  is  cold  and 
clammy,  the  heart's  action  slow  and  feeble,  and  the  bowels 
constipated. 

Course.  —  The  usual  course  in  the  catatonic  form  is  de- 
pression and  stupor,  followed  by  excitement,  passing  into 
dementia.  In  a  few  cases  the  stupor  is  immediately  fol- 
lowed by  dementia  without  the  intervention  of  the  charac- 
teristic excitement.     Occasionally  the  excitement  precedes 


DEMENTIA  PRECOX  253 

the  stupor  and  may  even  appear  at  the  very  onset  of  the 
disease. 

A  prominent  feature  in  the  course  of  the  disease,  which 
rarely  appears  in  other  forms  of  dementia  prsecox,  is  the 
remissions.  Remissions  for  a  few  days  or  a  few  hours  occur 
in  almost  all  of  the  cases.  The  consciousness  of  the  patients 
becomes  perfectly  clear.  They  apprehend  and  remember 
events,  are  quiet  and  rational,  and  often  express  a  feeling 
of  illness.  At  these  times  close  observation  discloses  a 
certain  constraint  in  manner  and  actions,  an  inconsistent 
emotional  attitude,  and  a  lack  of  full  appreciation  of  their 
previous  condition.  These  brief  remissions  occur  most 
frequently  in  the  states  of  excitement  and  are  both  less 
frequent  and  less  complete  in  stupor.  In  at  least  twenty 
per  cent,  of  all  the  cases,  the  remissions  are  long  enough  for 
the  patients  to  seem  to  have  completely  recovered.  Yet, 
in  these  cases,  one  often  detects  peculiarities  which  indicate 
that  recovery  is  not  complete,  such  as  irritability,  seclusive- 
ness,  and  forced,  affected,  or  constrained  manners.  A  re- 
lapse usually  occurs  within  the  first  five  years,  though  it 
may  not  come  within  fifteen  years. 

The  outcome  in  fifty-nine  per  cent,  of  the  cases  is  ulti- 
mately pronounced  mental  deterioration.  In  these  cases, 
the  stupor  and  excitement  disappear  and  the  hallucinations 
and  delusions  become  less  prominent,  but  the  patients  give 
numerous  evidences  of  dementia.  They  are  stupid  and 
indifferent,  and  have  lost  their  mental  activity.  They  are 
able  to  comprehend  simple  questions,  but  they  lack  mental 
initiative.  The  memory  is  defective,  the  judgment  poor,  and 
they  are  unable  to  acquire  new  knowledge.  They  have  no 
regard  for  themselves,  their  personal  appearance,  or  their 
future.  They  remain  contented  wherever  they  happen  to 
be,  and  never  express  any  desires.    They  are  wholly  unfit 


254  FORMS  OF  MENTAL  DISEASE 

for  intellectual  employment,  as  they  have  no  idea  of  how  to 
work.  Upon  questioning,  and  in  a  few  cases  voluntarily, 
delusions  and  hallucinations  are  expressed;  the  former  are 
usually  expansive  but  quite  incoherent,  and  without  effect 
upon  the  conduct  of  the  patient. 

Some  of  the  patients  are  very  inactive,  remaining  stupidly 
in  one  place  most  of  the  time,  sometimes  muttering  to  them- 
selves, but  taking  no  interest  in  their  surroundings.  Other 
patients  are  active,  restless,  and  unbalanced.  In  both  of 
these  groups,  and  especially  in  the  latter,  we  find  mannerisms. 
The  movements  lack  freedom,  are  constrained  and  peculiar; 
the  patients  walk  on  tiptoe,  along  cracks,  or  with  bent  limbs, 
with  head  thrown  forward  and  with  cramped  hands.  The 
head  is  usually  held  in  peculiar  positions.  When  sitting, 
they  always  assume  fixed  positions,  shaking  or  nodding  the 
head  at  regular  intervals,  making  a  blowing  noise  with  the 
lips  or  grunting.  They  pass  to  meals  only  through  certain 
doors,  or  perhaps  backwards.  The  mannerisms  are  es- 
pecially marked  in  dressing  and  at  table.  They  may  eat 
with  great  rapidity,  filling  the  mouth  to  its  fullest  extent 
before  swallowing.  Others  eat  very  deliberately,  waiting 
a  certain  interval  between  mouthfuls,  perhaps  counting 
three,  each  bit  of  food  being  prepared  and  carried  to  the 
mouth  in  a  certain  definite  manner.  Many  patients  eat 
with  their  hands,  others  hold  the  knife  and  fork  in  some 
peculiar  fashion.  One  of  my  patients  refused  to  eat  unless 
he  had  been  allowed  to  stand  on  his  head  and  crawl  under 
the  table.  Similar  mannerisms  are  evident  in  speech  and 
writing.  In  speech,  neologisms  may  prevail,  especially 
during  the  transitory  periods  of  excitement,  when  in  addi- 
tion there  may  be  a  genuine  word-jumble. 

The  deterioration  gradually  deepens,  particularly  follow- 
ing the  short  periods  of  excitement,  which  appear  in  most 


DEMENTIA  PRECOX  255 

cases.  At  these  times  the  patients  are  restless,  irritable, 
and  threatening,  and  express  delusions  of  persecution.  The 
speech,  in  addition  to  shouting  and  laughing,  shows  marked 
confusion.  Impulsiveness  also  is  prominent,  as  seen  in 
the  destructiveness,  aggressiveness,  and  even  homicidal 
attempts. 

In  twenty-seven  per  cent,  of  the  cases  the  dementia  is  of  a 
lighter  grade.  Here  the  patients  return  to  clear  conscious- 
ness, are  quiet  and  orderly,  able  to  return  home,  and  in  a 
few  cases  resume  their  former  occupations.  But  a  profound 
change  in  character  has  occurred;  their  former  mental 
vigor  does  not  return,  they  are  listless,  dull,  and  lack  energy 
and  endurance.  Their  judgment  is  defective.  They  are 
cleanly  and  orderly  in  conduct  except  for  a  few  catatonic 
mannerisms.  Some  of  the  patients  are  very  quiet,  seclusive, 
distrustful,  or  self-conscious;  while  others  are  somewhat 
childish  and  silly. 

These  cases  not  infrequently  present  periodical  attacks  of 
excitement  very  similar  to  those  exhibited  in  manic-depressive 
insanity.  These  attacks  are  of  short  duration,  not  more 
than  a  few  days  or  weeks,  but  the  intervals  vary  greatly. 
The  patients  become  loquacious,  distractible,  less  accessible, 
are  elated,  and  have  a  pressure  of  activity  in  which  the  move- 
ments are  mostly  purposeless,  stereotyped,  and  character- 
ized by  impulsiveness.  These  periodical  attacks  may  not 
develop  until  after  several  years  have  elapsed.  There  should 
also  be  included  here  a  series  of  cases  in  which  there  is  a 
regular  alternation  between  brief  periods  of  excitement  and 
brief  intervals.  In  women  these  attacks  seem  to  bear  some 
relation  to  the  menses  (menstrual  insanity).  The  patients 
begin  to  laugh  much,  to  wink  their  eyes,  and  to  wander 
about;  then  there  suddenly  develops  an  extremely  active 
excitement.    The  weight  falls  rapidly,  sometimes  five   to 


256  FORMS  OF  MENTAL  DISEASE 

eight  pounds  in  twenty-four  hours.  The  improvement  comes 
almost  as  rapidly,  although  toward  the  end  of  the  attack 
there  is  a  slight  diminution  of  the  dazedness  and  activity. 
The  patients  become  clear  and  orderly,  but  for  a  time  con- 
tinue very  quiet,  apathetic,  and  rather  stupid,  and  usually 
fail  to  gain  an  insight  into  their  condition,  although  they 
may  be  able  to  recall  several  incidents  of  their  psychosis. 
The  weight  is  regained  rapidly.  These  attacks  may  recur 
at  intervals  of  one  to  three  weeks  for  a  long  time.  In  the 
greater  number  of  these  cases  the  intervals  become  shorter, 
but  in  either  event  there  ultimately  develops  a  condition  of 
profound  dementia. 

About  thirteen  per  cent,  of  the  cases  seem  to  recover.  Some 
of  these  patients  manifest  slight  peculiarities  in  conduct 
and  a  change  in  character  which  is  apparent  only  to  those 
closely  associated  with  them.  A  number  of  these  cases 
later  in  life  suffer  from  another  attack,  terminating  in 
dementia. 

Unfortunately,  it  is  impossible  to  determine  what  cases 
will  recover,  what  cases  will  have  long  remissions  or  will 
become  deteriorated.  This  much  can  be  said,  however, 
that  those  with  an  acute  development,  also  those  in  which 
the  stupor  or  excitement  is  very  pronounced,  are  more  apt 
to  have  a  remission.  Marked  improvement  is  not  a  favorable 
indication,  provided  that  with  the  clearing  of  consciousness, 
there  is  not  a  corresponding  improvement  in  the  emotional 
attitude;  if  senseless  delusions  are  expressed  without  cor- 
responding effect  or  excitement ;  if  mannerisms  and  stereo- 
typy persist;  and  finally,  if  there  is  a  recurrence  of  periods 
of  excitement.  Prolonged  stupor  of  itself  does  not  neces- 
sarily indicate  deterioration,  as  patients  have  remained  in 
stupor  from  three  to  five  years. 

The  fatal  termination  of  the  catatonic  cases  usually  occurs 


DEMENTIA  PRECOX  257 

as  the  result  of  some  intercurrent  disease,  of  which  tuber- 
culosis is  the  most  prominent. 

Paranoid   Forms 

In  both  the  hebephrenic  and  catatonic  forms  of  de- 
mentia praecox  delusions  are  characteristic,  but  they  tend 
to  fade  within  a  short  time.  In  the  paranoid  forms  of  the 
disease,  on  the  other  hand,  delusions  and  usually  also  hal- 
lucinations persist  for  many  years,  although  there  are  evidences 
of  a  more  or  less  rapid  deterioration  while  consciousness  re- 
mains clear.  The  paranoid  forms,  comprising  twenty-two 
per  cent,  of  the  entire  group  of  dementia  praecox,  consist  of 
two  groups  of  cases. 

First  Group  (dementia  paranoides). — This  group  is 
characterized  by  the  persistence  of  numerous  incoherent 
and  changeable  delusions  of  both  a  persecutory  and  an 
expansive  nature  associated  with  a  moderate  degree  of 
excitement,  and  a  rather  rapidly  developing  dementia. 

Symptomatology.  —  The  onset  of  the  disease,  as  in  the 
other  forms,  follows  a  period  of  headache,  malaise,  and  in- 
somnia with  a  rapid  loss  of  energy  and  often  irritability. 
The  patients  act  peculiarly,  are  unusually  devout,  seem 
depressed  and  anxious,  and  remain  alone.  Very  soon  they 
divulge  a  host  of  delusions,  almost  entirely  of  persecution; 
people  are  watching  them,  intriguing  against  them,  they 
are  not  wanted  at  home,  former  friends  are  talking  about 
them  and  trying  to  injure  their  reputation.  These  delusions 
are  changeable  and  soon  become  fantastic.  The  patients 
claim  that  some  extreme  punishment  has  been  inflicted  upon 
them,  they  have  been  shot  down  into  the  earth,  have  been 
transformed  into  spirits,  and  must  undergo  all  sorts  of  tor- 
ture. Their  intestines  have  been  removed  by  enemies  and 
are  being  replaced  a  little  at  a  time;  their  own  heads  have 


258  FORMS  OF  MENTAL  DISEASE 

been  removed,  their  throats  occluded,  and  the  blood  no  longer 
circulates.  They  are  transformed  into  stones,  their  coun- 
tenances are  completely  altered,  they  cannot  talk,  eat,  or 
walk  like  other  men,  etc. 

Hallucinations,  especially  of  hearing,  are  very  prominent 
during  this  stage;  fellow-men  jeer  at  them,  call  them  bas- 
tards, threaten  them,  accuse  them  of  horrible  crimes,  and 
numerous  slanderous  telephone  messages  are  overheard. 
Occasionally  faces  and  forms  are  seen  at  night,  or  a  crowd 
of  men  throwing  stones  at  the  window.  Foul  vapors  may 
be  thrown  into  their  bedding. 

The  patients  show  agitation;  they  are  anxious,  restless, 
quarrelsome,  and  emotional.  They  laugh,  cry,  and  sing. 
The  orientation  is  not  disturbed.  In  conduct,  they  may 
perform  all  kinds  of  serious  and  outlandish  acts,  attempting 
suicide,  assaulting  persons,  and  committing  arson. 

The  emotional  attitude  soon  changes  and  becomes  more 
and  more  exalted.  At  the  same  time  the  delusions  become 
less  depressive  and  more  expansive  and  fantastic.  The 
patient  in  spite  of  persecution  is  happy  and  contented,  ex- 
travagant and  talkative,  and  boasts  that  he  has  been  trans- 
formed into  the  Christ;  others  will  ascend  to  heaven,  have 
lived  many  lives,  and  traversed  the  universe.  They  have 
the  talent  of  poets,  have  been  nominated  for  President, 
and  have  represented  the  government  at  foreign  courts. 
These  delusions  may  become  most  florid,  foolish,  and  ridicu- 
lous. A  patient  may  say  that  he  is  a  star,  that  all  light  and 
darkness  emanate  from  him;  that  he  is  the  greatest  in- 
ventor ever  born,  can  create  mountains,  is  endowed  with 
all  the  attributes  of  God,  can  prophesy  for  coming  ages,  can 
talk  to  the  people  in  Mars;  indeed,  is  unlike  anything  that 
has  ever  existed. 

Associated  with  these  variegated  and  ever  changing  ex- 


DEMENTIA  PRECOX  259 

pansive  delusions  there  are  delusions  of  persecution  almost 
as  absurd  and  extreme,  but  expressed  without  correspond- 
ing emotion.  Patients  smilingly  complain  that  they  have 
been  deprived  of  their  limbs,  have  been  pierced  with  thou- 
sands of  bullets,  and  been  thrown  into  hell,  where  they  were 
exposed  to  furnace  flames.  Suggestions  for  many  of  these 
delusions  may  be  obtained  from  pictures  on  the  wall  or  from 
reading.  The  hallucinations  also  become  more  extreme. 
Angels  descend  from  heaven  and  commune  with  them  daily, 
God  also  talks  to  them,  the  President  directs  their  conduct, 
beautiful  visions  are  displayed  at  night  which  are  full  of 
meaning. 

These  patients  are  usually  talkative  and  express  freely 
their  many  delusions.  Some  of  them  fill  hundreds  of  sheets 
of  paper  trying  to  describe  them.  At  first  they  are  quite 
coherent,  but  later  there  is  such  a  wealth  of  ideas  loosely 
expressed  that  it  is  difficult  to  follow  them.  They  wander 
aimlessly  about  from  one  delusion  to  another,  and  show 
frequent  repetitions  of  the  same  ideas.  Questions,  however, 
are  answered  in  a  coherent  and  relevant  manner.  Later 
in  the  course  of  the  disease  the  speech  becomes  more  and 
more  difficult  of  comprehension,  because  of  the  number 
of  peculiar  phrases  and  neologisms  to  which  they  attach 
special  significance  and  freely  repeat.  The  writings  like- 
wise become  more  and  more  unintelligible. 

The  patients  rarely  possess  insight  into  their  condition. 
The  consciousness  usually  becomes  somewhat  clouded,  es- 
pecially later  in  the  disease.  Orientation  as  to  place  is 
least  disturbed,  but  people  are  soon  mistaken  and  often 
designated  as  celebrated  personages,  and  all  conception  of 
time  is  lost.  Patients  recognize  relatives  and  can  give  a  fairly 
clear  statement  as  to  where  they  are.  They  may  recall 
some  past  knowledge,  but  they  soon  become  unable  to  use 


260  FORMS  OF  MENTAL  DISEASE 

it  in  reasoning  and  utterly  fail  to  follow  long  conversations. 
They  cannot  apply  themselves  to  any  mental  work.  The 
patients  show  an  exaltation  of  the  ego  with  heightened 
feelings,  they  are  self-conscious,  with  an  important  manner, 
and  demand  special  attention.  In  emotional  attitude  they 
are  almost  always  exalted,  rarely  depressed,  although  a  few 
patients  show  restlessness,  some  irritability,  and  occasionally 
some  passion,  often  in  connection  with  the  menses.  In- 
creased sexual  excitement  is  also  common.  Some  patients 
are  able  to  do  some  mechanical  work,  but  need  supervision 
because  of  their  capriciousness  and  fickleness. 

Physical  Symptoms.  —  There  is  very  little  physical  dis- 
turbance except  the  loss  of  weight  and  insomnia  at  the  on- 
set, faulty  nutrition,  and  occasionally  increased  vasomotor 
irritability  with  easy  blushing  and  blanching. 

Course.  —  The  course  is  progressive  without  remissions. 
The  signs  of  mental  deterioration  may  appear  within  a  few 
months,  and  are  usually  well  marked  by  the  end  of  two  years. 

The  patients  may  for  a  long  time  retain  clear  conscious- 
ness and  partial  orientation,  but  the  content  of  thought 
becomes  thoroughly  incoherent  and  there  is  a  lack  of  energy 
and  plan  in  their  activity,  which  incapacitates  them  for  all 
mental  application.  While  active  and  somewhat  interested 
in  their  environment,  they  still  display  a  self-conscious 
serenity.  From  this  stage  of  dementia  there  may  be  no 
further  progress  for  a  number  of  years.  Occasionally  tran- 
sitory exacerbations  of  excitement  or  depression  occur. 
Finally  there  may  be  periods  when  the  patients  disclaim 
their  delusions  and  refer  to  them  as  foolishness,  but  at  the 
same  time  they  do  not  regain  clear  insight. 

Second  Group.  —  There  is  provisionally  grouped  here  a 
larger  series  of  cases  which  are  characterized  by  fantastic 
delusions  usually  accompanied  by  numerous  hallucinations 


DEMENTIA  PRECOX  261 

which  are  more  coherently  developed  and  expressed  for  a  num- 
ber of  years,  when  they  either  become  incomprehensible  or  dis- 
appear altogether,  leaving  the  patients  in  a  condition  of  mod- 
erate dementia. 

Symptomatology.  —  The  first  symptoms  to  appear  are 
those  of  despondency  with  some  self-accusation.  The  pa- 
tients are  troubled  with  thoughts  of  death  and  religious 
doubts;  they  are  unusually  devout,  and  seek  religious  ad- 
vice. They  fear  that  they  have  done  wrong,  have  committed 
some  crime,  or  are  suffering  the  penalty  of  self-abuse.  Co- 
herent delusions  of  persecution  develop  gradually;  people 
watch  them,  peculiar  actions  are  noticed,  acquaintances 
are  less  friendly,  and  children  on  the  street  jeer  and  laugh 
at  them,  perhaps  mimicking  their  manners.  Strangers  on 
the  street  turn  and  stare.  In  public  places,  in  the  cars,  and 
at  the  church,  they  observe  peculiar  acts  which  refer  to  them. 
They  believe  themselves  libelled  by  the  newspapers.  They 
understand  these  mysterious  occurrences  and  will  shortly 
expose  the  offenders  and  bring  them  to  justice.  Affairs  at 
home  are  unsatisfactory;  the  children  are  different,  and  the 
husband  or  wife  is  unfaithful. 

Hallucinations,  especially  of  hearing,  rarely  of  sight,  are 
prominent  at  this  time,  aiding  in  the  elaboration  of  the 
delusions.  Enemies  take  advantage  of  their  confinement 
by  standing  below  the  window,  calling  them  all  sorts  of  names, 
announcing  that  they  are  to  be  imprisoned,  that  they  have 
committed  murder,  and  are  to  be  put  to  the  rack.  Voices 
are  heard  from  the  walls  and  from  under  the  floor,  stating 
that  they  are  wretches  and  outcasts  of  society.  Very  often 
the  noises  really  heard,  such  as  the  blowing  of  whistles  and 
the  ringing  of  bells,  are  misinterpreted  in  accord  with  their 
delusions.  They  complain  that  the  food  contains  poison 
which  they  can  taste,  they  suspect  phosphorus  in  the  tea 


262  FORMS  OF  MENTAL  DISEASE 

and  detect  kerosene  on  the  clothing.  They  notice  that 
their  clothing  is  changed,  buttons  are  missing,  there  is  a 
rip  in  the  coat  and  a  pocket  torn.  Objects  in  their  surround- 
ings are  changed  in  order  to  confuse  them. 

Delusions  of  physical  influence  become  particularly  promi- 
nent. Many  common  somatic  sensations,  such  as  twitch- 
ing of  individual  muscles,  headache,  specks  before  the  eyes, 
pain  about  the  heart,  and  cramp  in  the  bowels  are  all  evi- 
dences of  such  influences  wielded  by  their  enemies.  The 
explanations  of  these  somatic  sensations  are  often  most 
fantastic.  An  itching  of  the  foot  is  sufficient  evidence 
that  a  poisonous  powder  has  been  blown  into  their  shoes, 
pain  in  the  back  indicates  that  they  have  been  shot  there 
while  asleep,  a  frontal  headache  is  the  result  of  poisonous 
vapors,  which  are  set  free  in  the  room  at  night  in  order  to 
destroy  their  intellect.  A  tremor  of  the  fingers  is  pro- 
duced by  means  of  electric  currents  sent  through  the 
air.  Something  is  placed  in  their  food  to  create  sexual 
excitement. 

Their  persecutors  employ  the  most  varied  means  in  pro- 
ducing physical  discomfort.  All  known  agencies  are  men- 
tioned, as,  magnetism,  hypnotism,  X-rays,  telepathy,  and 
electricity.  Organs  of  the  body  are  removed  and  then  re- 
placed out  of  order,  and  the  intestines  are  shrunken.  It  is 
quite  characteristic  for  the  patients  to  refer  to  these  physi- 
cal changes  by  some  invented  names,  such  as,  ugly  duberty, 
snicking,  lobster  cracking,  etc.  Others  complain  that  their 
minds  are  influenced,  their  thoughts  are  gone,  they  have 
no  control  over  their  thoughts,  which,  in  spite  of  themselves, 
are  always  evil.  They  attribute  the  origin  of  such  thoughts 
to  others.  Frequently  they  complain  of  "  drawing  of  the 
thoughts,"  and  they  may  say  that  they  don't  know  whether 
their  thoughts  are  their  own  or  suggested  by  some  one  else. 


DEMENTIA  PRECOX  263 

Sometimes  their  thoughts  become  audible  (double  thought), 
especially  when  reading.  Their  thoughts  are  known  to  the 
whole  world. 

Ideas  of  spirit-possession  are  often  a  prominent  feature. 
Here  the  enemy  enters  and  takes  possession  of  the  body, 
causing  the  bones  to  crack  and  the  head  to  rattle;  obscene 
remarks  proceed  from  the  stomach;  their  ears  are  filled  by 
all  sorts  of  noises  made  by  these  spirit-possessors.  They 
cause  the  testicles  to  fall  and  the  throat  to  dry  up. 

In  connection  with  the  delusions  of  influence  there  de- 
velops in  almost  all  cases  more  and  more  pronounced  expan- 
sive delusions.  These  are  as  variegated  and  fantastic  as 
those  of  persecution.  The  patients  have  been  awarded  a 
prize  for  bravery  and  now  rule  the  country,  possess  beautiful 
dresses,  and  are  betrothed  to  the  king,  etc.  God  daily 
appears  to  them  and  gives  them  a  blessing.  They  have 
recently  been  intrusted  with  millions  which  they  are  to  in- 
vest in  mining.  They  have  consummated  an  immense 
trust,  of  which  they  are  president.  All  of  the  many  delusions 
expressed  by  the  patients  are  at  first  coherent,  and  may  be 
partially  systematized;  but  in  the  course  of  a  few  years,  they 
tend  to  become  somewhat  incoherent,  and  at  the  same  time 
the  hallucinations  become  more  agreeable. 

The  consciousness  during  the  development  of  these  de- 
lusions, and  for  a  long  time  afterward,  perhaps  years,  re- 
mains clear,  and  the  patients  are  oriented.  Thought  is 
coherent,  but  centers  about  the  delusions.  The  patients  are 
able  at  first  to  offer  some  basis  for  the  delusions,  to  refute 
objections,  and  to  show  some  "method"  in  their  ideas; 
but  later,  as  deterioration  appears  gradually  in  the  course  of 
several  years,  thought  becomes  confused,  and  the  delusions 
incoherent,  contradictory,  and  changeable.  There  is  rarely 
insight  into  the  disease.     Many  patients  appreciate  that  they 


264  FORMS  OF  MENTAL  DISEASE 

are  not  normal,  but  their  defects  and  ailments  are  rather 
regarded  as  the  work  of  their  persecutors. 

The  emotional  attitude  is  at  first  one  of  depression,  with 
anxiety  and  combativeness,  but  later  this  gives  way  to  a 
certain  amount  of  happiness  and  cheerfulness,  with  con- 
siderable egoism.  There  may  be  transitory  outbreaks  of 
anxiety  as  well  as  of  irritability.  In  some  cases  stuporous 
states  have  been  observed. 

The  conduct  is  mostly  in  accord  with  the  delusions;  the 
patients  are  suspicious,  journeying  about  to  get  rid  of  their 
enemies,  applying  to  police  for  protection;  or,  taking  the 
matter  in  their  own  hands,  they  attack  supposed  persecutors 
or  attempt  to  expose  them  through  the  papers.  Others  for 
self-protection  contrive  a  sort  of  armor  for  themselves,  place 
metals  in  their  shoes  or  wires  in  their  clothing  to  divert  the 
electrical  currents,  etc.  In  accord  with  expansive  delusions 
they  may  decorate  themselves  in  fantastic  costumes,  adorn 
themselves  with  badges,  assume  a  superior  air,  and  use  high- 
flown  language. 

Furthermore,  during  the  course  of  the  disease  peculiarities 
of  conduct  develop,  such  as,  grimacing,  striking  gesticu- 
lations, mannerisms  in  eating,  walking,  and  speaking,  as 
well  as  signs  of  negativism  or  of  stereotypy. 

Course. — The  duration  of  the  disease  extends  through 
many  years.  It  is  sometimes  possible  to  discern  certain 
stages  in  its  development:  at  first  a  change  of  disposition, 
then  a  prominence  of  delusions  of  persecution,  later  the 
appearance  of  delusions  of  grandeur,  indicating  the  onset 
of  deterioration,  and  finally  the  fading  away  and  entire 
collapse  of  the  delusions.  Remissions  in  the  symptoms 
may  occur.  The  outcome  is  always  deterioration.  The 
rapidity  with  which  the  dementia  develops  varies  greatly. 
Usually  some  signs  of  dementia  appear  within  two  or  three 


DEMENTIA  PILECOX  265 

years.  On  the  other  hand,  there  are  cases  which  deteriorate 
within  a  few  months,  and  there  are  others  which  do  not 
dement  for  a  number  of  years. 

In  some  cases  the  delusions  gradually  fade,  are  never  ex- 
pressed, are  forgotten  or  wholly  denied,  and  at  the  same 
time  there  appears  some  insight.  But  in  all  these  cases 
there  still  remains  some  impairment  of  memory  and  judg- 
ment, apathy,  and  a  loss  of  the  characteristic  energy  and 
activity.  Or  the  delusions  and  hallucinations  may  be  re- 
tained, while  the  patients  become  quite  indifferent  to  them, 
and  rarely  complain  of  persecutions  or  show  agitation. 
They  are  usually  capable  of  employment,  and  sometimes 
are  even  industrious,  the  former  "  Pope  "  becoming  a  trusted 
farm-hand,  and  the  "  queen  "  a  good  seamstress. 

More  frequently  the  outcome  is  characterized  by  an  in- 
creasing confusion  of  thought,  when  the  delusions  become 
more  and  more  incoherent  and  unintelligible,  while  the 
peculiarities  of  conduct  increase  with  a  tendency  to  occa- 
sional states  of  excitement  and  impulsiveness.  If  the  dete- 
rioration advances  further,  the  patients  may  reach  a  stage 
of  silly,  quiet  dementia. 

Diagnosis  of  dementia  praecox.  —  There  are  not  only  no 
pathognomic  signs  of  dementia  prsecox,  but  even  some_of  the 
more  characteristic  signs  of  the  disease,  such  as,  negativism, 
auTolhaHsiriTstereotypy,  and  mfl.nnp.rism,  occur  in  other  dis- 
eases^ for  instance,  paresis,  senile  and  other  organic  psychoses, 
as  well  as  in  some  of  the  infection  psychoses,  and  even  in 
manic-depressive  and  epileptic  insanity.  Hence  the  diagnosis 
must  rest  on  the  entire  picture  and  not  upon  arrysmgle 
symptom.  While  it  is  possible  that  different  disease  pro- 
cesses may  exhibit  at  times  similar  groups  of  symptoms,  it 
is  altogether  improbable  that  these  same  diseases  will  at 
all  times  resemble  each  other,  both  as  regards  the  manner 


266  FORMS  OF  MENTAL  DISEASE 

in  which  the  symptoms  develop,  their  course,  and  their  out- 
come. 

The  slowly  developing  cases  of  hebephrenia  must  be 
distinguished  from  acquired  neurasthenia.  This  differentia- 
tion depends  especially  upon  the  presence  of  signs  of  demen- 
tia, the  silliness  of  the  hypochondriacal  ideas,  especially 
sexual  hypochondria,  faulty  judgment,  emotional  apathy, 
and  the  fact  that  the  patients  do  not  improve  with  quiet  and 
relaxation.  The  emotional  apathy  of  the  hebephrenic 
stands  out  in  contrast  to  the  increased  emotional  irritability 
of  the  neurastheniac.  Finally,  any  evidences  of  hallucina- 
tions, of  automatism,  or  stereotypy  distinctly  indicate 
dementia  praecox  (see  also  p.  155). 

The  differentiation  of  dementia  praecox,  occurring  in  mid- 
dle life,  from  paresis  in  which  the  physical  symptoms  have 
not  yet  appeared,  may  be  quite  difficult.  The  catatonic 
symptoms  that  occasionally  occur  in  paresis  —  catalepsy, 
mutism,  verbigeration,  and  stereotypy  —  are  by  no  means 
as  varied  and  characteristic  as  in  catatonia;  while  the  general 
incapacity  and  genuine  weakness  of  will  is  more  prominent 
in  contrast  to  the  eccentricities  and  the  unruliness  of  the 
catatonic.  Furthermore,  the  mental  deterioration  in  paresis 
is  apt  to  be  more  rapid  and  more  profound  and  character- 
ized by  greater  disorder  of  the  apprehension,  orientation,  and 
impressibility  of  memory,  while  these  faculties  in  compari- 
son with  the  emotional  stupidity  and  the  weakness  of  judg- 
ment in  dementia  praecox  are  retained  for  a  relatively  long 
time,  although  they  may  be  temporarily  overpowered  by  neg- 
ativism. The  appearance  of  definite  hallucinations  and  of 
persistent  mannerisms  speaks  for  dementia  praecox.  The 
speech  disturbances  of  the  paretic  may  be  closely  simulated 
by  the  mannerisms  of  dementia  praecox;  even  epileptiform 
and  apoplectiform  attacks  may  occur  in  dementia  praecox. 


DEMENTIA   PRECOX  267 

In  such  doubtful  cases  one  must  depend  upon  the  lymphocy- 
tosis in  the  cerebrospinal  fluid  as  determined  by  lumbar 
puncture  and  the  microscopic  examination  of  the  fluid 
(see  p.  103). 

In  the  acutely  developing  cases  of  dementia  praecox,  the 
clouding  of  consciousness  and  the  confusion  of  speech  often 
render  it  difficult  to  distinguish  amentia.  Here  one  must 
depend  upon  the  presence  of  negativism,  stereotypy,  and 
automatism.  If  the  latter  are  present  in  amentia,  they  are  not 
marked.  In  amentia,  the  patients  are  more  natural  in  their 
acts,  less  constrained,  and  not  silly  and  eccentric.  The 
orientation  and  impressibility  of  memory  is  far  more  dis- 
turbed in  amentia  than  in  dementia  praecox.  The  amentia 
patient,  in  spite  of  his  best  efforts,  is  unable  to  solve  long 
mental  problems,  loses  the  thread  in  long  conversations,  and 
indulges  in  incoherent  reminiscences,  yet  he  is  able  to  answer 
some  questions  rapidly  and  to  the  point.  On  the  other  hand, 
the  dementia  praecox  patient  answers  in  a  silly  manner  or 
perhaps  not  at  all.  Again  at  times  he  surprises  one  by 
his  correct  conversation,  and  his  thoughtful,  bright  remarks, 
or  he  even  solves  a  difficult  problem  and  recalls  correctly 
historical  and  geographical  facts.  In  amentia  the  emotional 
attitude  is  exceedingly  changeable  from  depression  to  ex- 
altation and  vice  versa,  while  in  dementia  praecox,  even 
during  excitement,  a  certain  emotional  stolidity  and  apathy 
prevails.  The  amentia  patient  may  not  have  a  very  accu- 
rate knowledge  of  the  surroundings,  yet  he  attends  to  and 
watches  what  takes  place ;  but  in  dementia  praecox  the  pa- 
tient exhibits  remarkably  little  interest  in  those  things 
that  he  comprehends  well.  Finally,  in  amentia  there  is 
always  a  history  of  some  exhausting  etiological  factor, 
which  only  occasionally  antedates  dementia  praecox. 

Beginning  cases  of  catatonia  may  be  mistaken  for  epileptic 


268  FORMS  OF  MENTAL  DISEASE 

befogged  states,  particularly  when  an  epileptiform  attack  has 
occurred.  The  negativism  of  the  catatonic  contrasts  with 
the  anxious  resistance  of  the  epileptic,  while  orientation  is 
much  more  disturbed  in  the  epileptic.  Silly  answers  to 
simple  questions  and  rapid  and  correct  obedience  to  com- 
mands speaks  for  catatonic.  In  epileptics  an  anxious  or 
ecstatic  emotional  attitude  prevails.  The  epileptic  is  much 
more  apt  to  make  frequent  assaults  and  attempts  at  escape, 
while  the  impulsive  acts  of  the  catatonic  are  purposeless 
and  manneristic. 

The  greatest  difficulty  arises  in  distinguishing  the  depres- 
sive phases  of  manic-depressive  insanity  from  the  periods 
of  depression  which  one  encounters  at  the  onset  of  the  hebe- 
phrenic and  the  catatonic  forms.  The  early  appearance  of 
many  hallucinations  and  senseless  delusions,  especially 
ideas  of  physical  influence,  and  the  retention  of  a  clear  con- 
sciousness speak  for  dementia  praecox,  as  well  as  an  emo- 
tional attitude  which  does  not  correspond  to  the  depressive 
character  of  the  delusions.  The  catatonic  patient  remains 
quite  indifferent  during  the  visit  of  a  relative,  while  in  manic- 
depressive  depression  the  feelings  are  apt  to  be  intensified. 
Hypersuggestibility  of  the  will  may  exist  in  both  conditions, 
but  a  manic-depressive  patient  will  not  upon  request  pro- 
trude his  tongue  for  the  purpose  of  having  it  perforated  with 
a  needle.  The  uniform  lamentations  that  sometimes  occur 
in  manic-depressive  depression  are  the  expressions  of  a 
persistent  and  overwhelming  feeling  of  sadness,  and  not 
the  result  of  a  senseless  persevering  impulse.  The  condi- 
tions of  negativism  of  the  catatonic  and  of  anxious  resist- 
ance and  retardation  of  the  manic-depressive  are  at  times 
distinguished  only  with  difficulty.  In  the  former  there  is 
uniform,  rigid,  and  stubborn  resistance  to  every  passive 
movement,  and  if  pain  is  produced  by  pricking  the  eyelid, 


DEMENTIA  PRECOX  269 

there  is  a  simple  withdrawal  without  effort  at  defence; 
while  in  retardation  the  passive  movements  are  mostly 
permitted.  In  case  the  retarded  patient  shows  some  resistance 
he  does  not  persist  in  returning  his  hand  to  the  same  position, 
and  if  one  threatens  to  approach  him  he  utters  an  outcry, 
shrinks  back,  or  defends  himself.  Voluntary  movements 
in  catatonic  stupor  are  rare,  but  when  executed  are  carried 
out  without  delay,  and  at  times  even  rapidly,  except  when 
these  movements  are  made  by  request,  then  there  is  always 
delay.  In  retardation,  all  voluntary  movements  are  carried 
out  very  slowly.  There  is  sometimes  a  certain  resistance 
due  to  apprehension  and  fear,  but  this  is  active. 

The  differentiation  between  manic-stupor  and  catatonic 
stupor  is  quite  difficult  and  depends  upon  the  character- 
istic happy  temperament,  distractibility  of  the  attention 
by  the  environment,  the  susceptibility  to  command,  the 
accessibility  to  conversation,  and  finally  the  occasional 
purposeful  and  frolicsome  character  of  the  movements  of 
manic-stupor  in  contrast  to  the  silliness,  indifference,  in- 
susceptibility, and  the  senseless  impulses  of  the  catatonic 
stupor. 

The  excitement  of  the  catatonic  is  to  be  distinguished 
from  the  excitement  of  the  manic  phases  of  manic-depressive 
insanity.  In  the  catatonic  excitement  the  clouding  of  con- 
sciousness is  less  marked  than  in  the  manic  excitement, 
the  patients  being  partially  oriented,  even  in  the  greatest 
excitement,  while  in  the  extreme  manic  states  there  is 
complete  disorientation.  On  the  other  hand,  the  speech  of 
the  catatonic  who  has  less  motor  excitement  is  more  senseless 
and  difficult  to  follow  than  that  of  the  manic  who  has  ex- 
treme motor  excitement.  The  catatonic  speech  abounds  in 
verbigerations  and  stereotyped  expressions  and  is  free  of  com- 
ments upon  the  surroundings,  while  the  speech  of  the  manic 


270  FORMS  OF  MENTAL  DISEASE 

presents  the  characteristic  flight  of  ideas,  and  is  centered 
upon,  or  drawn  largely  from,  the  immediate  surroundings. 
Also  attention  is  readily  distracted  by  the  surroundings, 
while  the  attention  of  the  catatonic  cannot  be.  The  emo- 
tional attitude  of  the  manic  is  exalted,  frolicsome,  and 
irritable,  while  that  of  the  catatonic  is  silly,  childishly 
happy,  and  indifferent.  The  movements  of  the  catatonic 
are  purposeless,  frequently  repeated,  in  contrast  to  the  press- 
ure of  activity  of  the  manic,  in  whom  the  movements  are 
always  purposeful,  related  to  the  surroundings,  dependent 
upon  ideas,  impressions,  and  emotions,  and  always  appearing 
in  new  forms.  In  catatonia  there  is  no  parallel  between  the 
excitement  in  speech  and  that  in  movement;  for  instance, 
the  patient  may  be  extremely  productive,  lying  quietly  in 
bed,  or  he  may  be  extremely  active  and  not  utter  a  word. 
The  increased  activity  of  the  catatonic  is  more  apt  to  be 
limited  to  one  corner  of  the  room  or  of  the  bed,  while  that 
of  the  manic  is  limited  only  by  his  confines,  and  in  addition 
to  this  the  individual  movements  of  the  catatonic  tend  to  be 
manneristic,  stilted,  unnatural,  and  associated  with  silly 
impulses;  those  of  the  manic,  natural  and  more  compre- 
hensible. 

The  extreme  excitement  of  the  paretic  may  resemble  closely 
the  catatonic  excitement.  In  addition  to  the  history  of  the 
development  of  the  disease,  the  age,  and  the  physical  signs, 
paresis  may  be  recognized  by  the  more  profound  clouding 
of  consciousness,  the  greater  disorientation,  and  disorder 
of  the  impressibility  of  memory. 

Dementia  prsecox,  especially  where  there  have  been  hys- 
terical attacks,  must  frequently  be  differentiated  from 
hysterical  insanity.  The  latter  fails  to  show  the  desultori- 
ness,  the  weakness  of  judgment,  the  indifferent  emotional 
attitude,  and  the  similarity  and  purposelessness  in  the  con- 


DEMENTIA  PRECOX  271 

duct  of  the  dementia  praecox  patient.  All  of  these  symp- 
toms stand  in  contrast  to  the  shrewdness,  capriciousness, 
slyness,  keenness,  tyranny,  and  the  purposeful  obstinacy 
of  the  hysteric.  Finally,  pronounced  hallucinations  and 
delusions  favor  dementia  praecox.  But  there  is  still  a  large 
number  of  cases,  which  present  at  the  outset  clear  symp- 
toms of  hysteria,  but  which  later  show  unmistakable  evi- 
dence of  the  deterioration  of  dementia  praecox.  The  very 
same  condition  may  exist  in  manic-depressive  insanity,  in 
epilepsy,  in  paresis,  and  in  brain  tumor,  which  would  favor 
the  view  that  in  constitutionally  defective  individuals  the 
early  stages  of  these  diseases  may  resemble  very  closely 
the  picture  of  hysteria. 

The  distinction  of  the  paranoid  forms  of  dementia  praecox 
from  pure  paranoia  depends  upon  the  lack  of  system,  the 
rapid  development  of  fantastic  delusions  commencing  with 
prominent  hallucinations;  while  in  paranoia  the  onset  is 
very  gradual,  sometimes  extending  over  one  year  with  only 
a  few  hallucinations.  The  delusions  in  dementia  praecox 
are  extremely  fantastic,  changing  beyond  all  reason,  with 
an  absence  of  system  and  a  failure  to  harmonize  them  with 
events  of  their  past  life;  furthermore,  the  delusions  of  phys- 
ical influence  are  very  prominent.  In  paranoia  the  delu- 
sions are  largely  confined  to  morbid  interpretations  of  real 
events,  are  woven  together  into  a  coherent  whole,  gradually 
becoming  extended  to  include  even  events  of  recent  date, 
while  contradictions  and  objections  are  apprehended  and 
explained.  In  emotional  attitude  the  dementia  praecox 
patients  soon  show  clear  and  marked  changes,  —  depression 
or  silly  elation,  sexual  excitement,  and  remissions;  while 
in  paranoia  the  emotional  attitude  is  uniformly  natural, 
the  demeanor  is  almost  normal,  and  the  patients  are 
capable    of    occupation   for   a    long   time.     In   paranoia 


272  FORMS  OF  MENTAL  DISEASE 

there  may  be  partial  remissions  when  the  patients  react 
less  actively  to  the  delusions,  but  the  delusions  never 
disappear. 

In  the  absence  of  history  of  the  early  life  and  of  the  psy- 
chosis, imbecility  may  be  confused  with  the  end  stages  of 
dementia  prsecox.  The  recognition  of  dementia  praecox 
then  depends  upon  the  presence  of  exacerbations  in  which 
dementia  praecox  signs  appear  and  occasional  utterances 
which  evince  extensive  earlier  knowledge. 

Treatment.  —  Our  meagre  knowledge  of  the  causes  of 
the  disease  restricts  the  indications  for  treatment  to  the 
individual  symptoms.  The  cases  which  develop  acutely 
or  subacutely  demand  careful  watching  in  order  to  prevent 
self-injuries  and  suicidal  attempts.  Unless  this  can  be 
accomplished  with  the  aid  of  a  sufficient  nursing  force  at 
home,  it  is  best  that  the  patient  be  sent  to  a  hospital.  Cases 
of  the  hebephrenic  form  with  gradual  onset  can  be  much 
more  safely  cared  for  at  home.  At  the  onset  in  all  forms  of 
the  disease  the  patient  must  be  placed  in  a  quiet  and  rest- 
ful environment,  free  from  all  irritating  circumstances, 
and  in  the  charge,  if  possible,  of  a  judicious  nurse.  It  is 
usually  advisable  that  the  patient  should  not  be  in  charge 
of  a  member  of  the  family.  In  the  acute  and  subacute 
cases,  bed  treatment  should  be  regularly  prescribed. 

The  insomnia  is  best  combated  by  the  simplest  measures,  as 
hot  baths  upon  retiring,  warm  liquid  nourishment,  or  the 
hot  or  cold  pack.  If  the  patient  does  not  secure  six  or  seven 
hours  sleep  by  the  simple  remedies,  one  may  resort  on  al- 
ternate nights  to  sparing  doses  of  some  hypnotic,  as,  trional, 
veronal,  somnos,  chloral,  or  paraldehyde.  These  drugs 
should  not  be  given  for  long  periods  without  being  alternated. 
Conditions  of  excitement  are  always  best  controlled  by  the 
prolonged  warm  bath  (see  p.  140),  at  first  preceded  by  a  pre- 


DEMENTIA  PEJECOX  273 

liminary  dose  of  hyoscine  hydrobromate  jp  to  -^  grain,  or 
scopalamine  hydrobroniid  in  the  same  dosage.  The  extreme 
excitement  sometimes  encountered,  especially  in  the  catatonic 
form,  may  not  yield  to  the  prolonged  warm  bath,  in  which 
event  one  can  often  successfully  employ  hot  or  cold  packs 
(see  p.  321).  These  packs,  however,  are  not  applied 
without  some  risk,  and  usually  require  the  supervision  of 
a  physician.  But  in  the  employment  of  any  sedative  it 
must  be  borne  in  mind  that  the  remedy  is  not  curative,  and, 
therefore,  it  is  not  advisable  to  employ  high  doses  in  order 
to  wholly  curb  the  excitement.  If  it  seems  essential  to 
secure  quiet  where  these  other  measures  have  failed,  one 
may  occasionally  resort  to  a  hypodermic  of  hyoscine  hydro- 
bromate -l^-q  with  morphine  sulphate  \  grain.  If  the  excite- 
ment is  still  unabated,  nothing  remains  but  confinement 
in  a  padded  room  with  careful  watching.  Simple  persuasion 
on  the  part  of  a  well-trained,  tactful  nurse  or  physician  often 
succeeds  in  bringing  about  quiet,  at  least  temporarily;  but 
this  requires  great  patience,  a  kindly  disposition,  and  self- 
control. 

While  the  condition  of  nutrition  demands  careful  atten- 
tion during  the  early  stages  of  the  disease,  it  becomes  par- 
ticularly urgent  during  the  stuporous  states.  The  patient 
should  eat  a  liberal  quantity  of  easily  digested  food.  In 
order  to  estimate  the  state  of  nutrition  such  cases  should 
be  regularly  weighed  at  least  once  a  week.  During  stupor 
with  refusal  of  food,  the  patient  should  not  be  permitted 
to  go  without  food  and  water  for  more  than  three  days. 
If  the  patient  is  illy  nourished,  one  should  resort  to  feeding 
by  stomach  or  nasal  tube  at  the  end  of  thirty-six  hours. 
The  patient  may  be  fed  artificially  two  or  three  times  daily, 
the  total  amount  aggregating  two  quarts  of  milk  with  six 
raw  eggs,  and,  if  need  be,  an  ounce  of  olive  oil,  varying 


274  FORMS  OF  MENTAL  DISEASE 

quantities  of  meat  juice,  and  stimulants,  particularly 
whiskey. 

The  excretory  functions  must  be  daily  watched,  particu- 
larly during  the  stuporous  states,  when  patients  retain  the 
feces  and  urine.  During  the  acute  manifestations  of  the 
disease,  frequent  high  flushings  of  the  lower  bowel  with 
normal  saline  solution  are  well  recommended. 

During  the  periods  of  despondency  at  the  onset  of  the 
disease,  in  addition  to  the  bed  treatment  already  referred 
to,  the  patient  should  be  given  an  opportunity  at  times 
during  each  day  to  leave  the  bed  for  short  periods  and  exer- 
cise. Furthermore,  simple  methods  of  occupying  the  mind, 
at  the  same  time  affording  some  diversion,  as,  reading,  play- 
ing games,  needlework,  etc.,  should  be  a  part  of  the  daily 
routine.  Friendly  encouragement,  with  a  frank  discussion 
of  the  various  delusions  and  hallucinations,  persistently 
carried  out  by  a  kindly  and  tactful  nurse  and  physician,  is 
not  the  least  important  feature  of  the  treatment,  and  must 
not  be  overlooked. 

As  the  more  acute  symptoms  improve  and  the  fear  and 
increased  activity  subsides,  the  patient  may  then  be  allowed 
to  leave  the  bed  for  longer  periods,  but  at  the  same  time  the 
graduated  exercise  and  mental  application  should  be  in- 
creased. The  whole  effort  of  the  physician  should  then 
be  directed  to  developing  remaining  mental  capacity  and 
preventing  further  mental  defect.  This  requires  a  consider- 
able amount  of  specialized  attention  in  the  individual  cases 
in  order  to  prescribe  means  that  at  the  same  time  are 
adapted  to  the  patients'  needs  and  traits  and  also  are 
suited  to  their  environment.  Very  many  patients  improve 
sufficiently  so  that  they  are  able  to  return  to  their 
homes  or  to  their  full  liberty.  But  in  advising  this,  one 
must  not  overlook  the  possibility  of  exacerbations,  and  in 


DEMENTIA  PRECOX  275 

women  the  possibility  of  pregnancy,  and  the  resumption  of 
excessively  burdensome  home  cares.  The  cases  exhibiting 
advanced  grades  of  deterioration  must  be  kept  under 
surveillance.  An  essential  feature  of  the  care  of  these 
mental  shipwrecks  is  healthful  employment,  preferably  out 
of  doors. 


VI.    DEMENTIA  PARALYTICA  (Paresis) 

Dementia  paralytica,1  or  general  paresis  of  the  insane,  is 
a  chronic  psychosis  of  middle  age,  characterized  by  progressive 
mental  deterioration  with  symptoms  of  excitation  of  the  central 
nervous  system,  leading  to  absolute  dementia  and  paralysis, 
and  pathologically,  by  a  fairly  definite  series  of  organic  changes 
in  the  brain  and  spinal  cord,  probably  the  result  of  some  toxin, 
in  the  origin  of  which  syphilis  is  most  often  an  important 
factor. 

Etiology.2  —  The  disease  is  unknown  among  the  unciv- 
ilized nations  and  is  most  prevalent  in  western  Europe 
and  North  America,  hence,  it  seems  to  be  a  disease  of 
modern  civilization.  In  America,  the  disease  comprises 
from  five  to  eight  per  cent,  of  the  admissions  to  insane 
institutions,  but  in  some  European  cities,  notably  Berlin 
and  Munich,  the  paretics  average  thirty-six  to  forty-five  per 
cent,  of  the  male  admissions.  The  disease  is  somewhat 
more  prevalent  in  large  cities  and  manufacturing  centers, 
while  it  is  relatively  rare  in  farming  communities.    The  pro- 

1  Voisin,  Traite  de  la  paralysie  generate  des  alienes,  1879 ;  Mendel,  Die 
progressive  Paralyse  der  Irren,  1880.  Mickle,  General  Paralysis  of  the 
Insane,  2.  ed.  1886.  v.  Krafft-Ebing,  Nothnagels  spezielle  Pathologie 
u.  Therapie,  Bd.  IX,  2, 1894.  Ilberg,  Volkmanns  klinische  Vortrage,  161 ; 
Binswanger,  Deutsche  Klinik,  VI,  2,  59,  1901. 

2  Diefendorf,  Brit.  Med.  Jour.,  No.  2387,  p.  744.  Wollenberg,  Archiv. 
f.  Psy.,  XXVI,  2.  Gudden,  ebenda.  v.  Krafft-Ebing,  Jahrb.  f.  Psy., 
XIII,  2  u.  3.  Oebecke,  Allgem.  Zeitschr.  f.  Psy.,  XL.  Hirschl,  Jahrb.  f. 
Psy.,  XIV,  321.  Bar,  Die  Paralyse  in  Stephansfeld,  Diss.,  Strassburg, 
1900. 

276 


DEMENTIA  PARALYTICA  277 

portion  of  male  to  female  paretics  is  1  to  3.9  to  7.  This  dispro- 
portion has  recently  gradually  decreased.  Negresses  show 
a  striking  tendency  to  the  disease;  in  Connecticut,  the 
negress  paretics  are  ten  times  more  prevalent  than  the 
female  white  paretics.  Women  suffer  more  often  from  the 
depressive  form  and  least  often  from  the  agitated  form,  and 
in  them  the  disease  lasts  longer.  Our  average  age  of  onset 
in  one  hundred  and  seventy-two  cases  is  forty-two  years. 
Kraepelin  in  two  hundred  and  forty-nine  cases  finds  that  it 
occurs  preeminently  in  middle  life,  as  eighty-one  per  cent,  of 
the  cases  occur  between  thirty  and  fifty  years,  the  disease 
rarely  appearing  before  twenty-five  or  after  fifty-five  years 
of  age.  The  average  age  of  onset  in  our  women  was  two  years 
younger  than  in  men,  and  one-third  of  the  women  became 
afflicted  between  thirty  and  thirty-five,  while  one-fourth  of 
the  cases  occurred  after  fifty  years.  Kraepelin,  however, 
finds  that  the  onset  in  women  averages  later.  In  our  ex- 
perience, the  onset  is  earlier  in  syphilitic  and  alcoholic 
women.  Our  natives  are  slightly  more  prone  to  paresis 
than  our  foreign-born. 

Recently  a  number  of  cases  of  juvenile  paresis l  have  been 
reported  occurring  between  the  ages  of  ten  to  twenty  years 
in  which  hereditary  paresis,  syphilis,  and  alcoholism  are 
prominent  factors.  Clinically,  the  juvenile  form  is  char- 
acterized by  simple  deterioration  of  three  to  four  years'  dura- 
tion with  numerous  paralytic  attacks,  choreic  disturbances, 
and  paralyses. 

The  disease  afflicts  chiefly  the  unmarried,  and  among  the 

1  Alzheimer,  Allgem.  Zeitschr.  f.  Psy.,  LII,  3.  Thiry,  De  la  paralysie 
progressive  dans  le  jeune  age,  1898.  Hirschl,  Wiener  Klin.  Wochenschr., 
1901,  21.  v.  Rad,  Archiv  f.  Psy.,  XXX,  82.  Mingazzini,  Monatsschr.  f. 
Psy.,  Ill,  53.  Frolich,  Uber  allgemeine  progressive  Paralyse  der  Irren 
vor  Abschluss  der  koerperlichen  Entwicklung,  Diss.,  1901. 


278  FORMS  OF  MENTAL  DISEASE 

women  especially  prostitutes;  in  our  experience  prostitutes 
are  forty-five  per  cent,  more  prone  to  the  disease  than  other 
women.  Married  women  are  usually  childless.  Not  infre- 
quently the  disease  occurs  in  man  and  wife;  sometimes 
tabes  is  present  in  one  and  dementia  paralytica  in  the  other 
and  paresis  occasionally  exists  in  the  parents.  The  male 
paretics  come  from  all  classes  and  from  most  professions 
and  trades,  though  the  disease  is  more  prevalent  among  hotel 
and  saloon  keepers,  quarrymen,  carriage  and  hack  drivers, 
bakers,  sailors,  hostlers,  mechanics,  masons,  salesmen,  and 
clerks,  and  least  prevalent  among  farmers,  servants,  and 
factory  employees.  Defective  heredity  is  comparatively  in- 
significant, except  in  juvenile  paresis,  as  it  occurs  in  only 
fifty  per  cent,  of  cases. 

Among  the  causes  of  the  disease,  syphilis  is  statistically 
the  most  prominent.  Its  prevalence  varies,  according  to 
various  authors,  from  one  and  six- tenths  per  cent,  to  ninety- 
three  per  cent.,  but  most  observers  place  it  between  thirty- 
four  and  sixty-five  per  cent.  In  our  experience  it  existed 
in  fifty-two  per  cent.  Gudden  in  the  Charite,  and  Kraepelin 
at  Heidelberg  cannot  establish  a  clear  history  of  syphilis  in 
more  than  thirty-four  per  cent,  of  male  paretics.  In  other 
psychoses,  we  find  syphilis  in  but  five  and  five-tenths  per 
cent,  of  the  cases.  Therefore,  there  seems  to  be  some  rela- 
tionship between  syphilis  and  paresis,  a  view  which  receives 
further  support  not  only  by  the  experiments  cited  by  Krafft- 
Ebing,  in  which  nine  paretics  inoculated  with  syphilis  failed 
to  develop  secondary  syphilic  lesions,  but  also  by  the  clinical 
observation  that  paretics  infected  with  syphilis  during  the 
disease  do  not  show  secondary  manifestations.  This  latter  is 
now  doubted  by  Marchand,  Gabiana,  and  Garbini,  who  have 
reported  seven  cases  in  which  paretics  developed  syphilis. 
Other  apparently  significant  facts  are  the  infrequency  of 


DEMENTIA  PARALYTICA  279 

paresis  in  women  of  the  better  classes  and  Catholic  priests, 
its  frequency  among  prostitutes,  and  the  occurrence  of  pare- 
sis in  man  and  wife.  Other  important  causes  are  excessive 
alcoholism,  which  existed  in  sixty  per  cent,  of  our  cases,  head 
injury  twenty-three  per  cent.,  and  mental  shock.  Finally,  a 
factor  which  cannot  be  overlooked  is  the  ensemble  of  modern 
life  with  its  restless  overactivity  and  insufficient  relaxation, 
coincident  with  the  struggle  for  existence  in  large  cities, 
and  the  common  excesses  in  eating  and  drinking. 

Pathology.  —  In  view  of  the  uniform  course  of  the  disease 
leading  to  dementia  and  nervous  paralysis,  accompanied  by 
a  general  and  extensive  destructive  process,  involving  not 
only  the  central  nervous  system,  but  also  the  general  vascular 
system,  and  to  a  limited  extent  the  internal  organs  of  the 
body,  it  seems  probable  that  we  have  to  do  with  a  toxic 
process.  There  exist  symptoms  of  excitation  of  the  neurones, 
their  rapid  destruction,  gradual  sclerosis,  occasional  exacer- 
bations of  the  symptoms,  and  the  possibility  of  a  regenera- 
tion of  the  neurones,  all  of  which  can  be  reproduced  by 
experimentation  upon  test  animals  with  any  toxic  material 
which  causes  a  destruction  of  the  neurones.  These  anatomi- 
cal facts  are  wholly  in  accord  with  the  clinical  observations ; 
namely,  the  gradual  onset,  great  clouding  of  consciousness, 
rapid  or  gradual  deterioration,  and  marked  remissions,  some 
of  which  almost  approach  complete  recovery.  The  vascular 
lesions  and  the  broad  extent  of  the  process  indicates  that 
the  toxin  reaches  the  neurone  by  means  of  the  blood  vessels. 
The  involvement  of  the  kidneys,  heart,  and  the  entire  vascular 
system,  the  fragility  of  the  bones,  the  alternate  loss  and  in- 
crease of  the  body  weight,  ending  at  last  in  great  emacia- 
tion, all  speak  for  the  profound  general  disturbance  of 
nutrition  of  which  the  mental  are  obviously  the  most  severe, 
but  not  the  only  symptoms. 


280  FORMS  OF  MENTAL  DISEASE 

The  sudden  and  high  elevation  of  temperature,  as  well 
as  the  prolonged  subnormal  temperature,  and  finally  the 
paralytic  attacks,  judging  from  our  experience  in  eclampsia, 
myxedema,  and  uremia,  can  best  be  explained  by  intoxica- 
tion arising  from  disturbance  of  metabolism.  Viewed  in 
this  light,  the  pathology  of  paresis  resembles  that  of  myxe- 
dema, diabetes,  osteomalacia,  and  acromegaly,  except  that  in 
these  diseases  the  toxin  does  not  involve  the  nervous  tissue. 

The  character  of  the  toxin  and  the  sources  from  which  it 
arises  are  questions  still  in  doubt.  Syphilis  cannot  be  the 
sole  cause  of  paresis,  as  long  as  it  does  not  exist  in  more  than 
thirty-four  to  sixty-five  per  cent,  of  the  cases.  Furthermore, 
paresis,  anatomically,  is  not  a  simple  syphilitic  process. 
Again  the  late  manifestations  of  syphilis  arise  within  a  com- 
paratively short  time  after  primary  symptoms,  while  paresis 
does  not  develop  until  ten  or  more  years  have  elapsed  after 
the  initial  lesion.  Taking  into  consideration  all  of  these 
facts,  the  only  acceptable  view  is  that  in  a  considerable 
number  of  cases  syphilis  somehow  produces  a  profound  change 
of  metabolism  which  in  turn  gives  rise  to  a  toxin,  which  second- 
ary product  is  the  direct  cause  of  the  pathological  changes  char- 
acteristic of  dementia  paralytica.  Other  apparent  etiological 
factors,  as,  alcohol,  head  injury,  lead,  and  excesses,  may  bear 
a  similar  causal  relation  to  this  disturbance  of  metabolism. 

Pathological  Anatomy.1 — The  pathological  changes  here 
enumerated  can,  as  a  whole,  be  regarded  as  pathognomic  of 
this  disease.  Hyperostoses  and  exostoses  of  the  cranium 
with,  but  more  especially  without,  thickening  of  the  tables, 
are  occasionally  present.  The  dura  is  usually  adherent  to 
the    calvarium    in    places.     Pachymeningitis    interna    and 

1  Nissl,  Monatsschr.  f.  Psy.,  TV,  413 ;  Allgem.  Zeitschr.  f .  Psy.,  LX, 
215.  Nacke,  ebenda,  LVII,  619.  Cramer,  Handbuch  der  pathol. 
Anatomie  des  Nervensystems  von  Flatau-Jacobsohn-Minor,  1470,  1903. 


DEMENTIA  PARALYTICA  281 

hematoma  are  common.  The  false  membrane  is  almost 
always  situated  on  the  vertex  over  the  frontal,  parietal,  or 
temporal  lobes,  and  is  of  varying  thickness,  from  a  thin, 
almost  imperceptible  rust-colored  membrane,  to  a  thick, 
firm,  white  membrane,  with  small  or  large,  fresh  or  partially 
absorbed  clots. 

The  pia  is  thickened,  whitish,  and  translucent  along  the 
vessels,  and  especially  over  the  vertex  of  the  frontal  and 
parietal  lobes  and  the  first  three  temporal  convolutions,  and 
rarely  over  the  occipital  lobes.  The  internal  surfaces  of  the 
frontal  poles  are  often  adherent.  The  leptomeningitis  is 
always  more  intense  over  the  poles  of  the  frontal  lobes. 
The  Pacchionian  granulations  are  usually  increased  in  size. 
The  pia  over  the  atrophied  convolutions  and  broadened 
fissures  often  contains  blebs  filled  with  serum.  The  con- 
volutions are  atrophied,  especially  in  the  frontal  lobes.  In 
these  portions  the  cortex  is  narrow  and  often  strongly 
adherent  to  the  pia,  tearing  upon  its  removal.  In  the  other 
portions  of  the  cortex,  and  in  the  basal  ganglia,  the  atrophy 
is  much  less  marked.  The  ventricles  are  dilated,  and  the 
choroid  plexuses  may  contain  many  cysts.  The  ependyma 
especially  of  the  fourth  ventricle,  and  the  inner  walls  of  the 
lateral  ventricles,  present  granulations,  which  give  the  usual 
glistening  surfaces  a  frosted  appearance.  These  granula- 
tions are  composed  of  an  increase  of  neuroglia,  which  in 
many  cases  has  undergone  hyaline  degeneration.  The 
weight  of  the  brain  is  regularly  below  normal,  and  in  some 
cases  of  long  duration  may  be  reduced  to  nine  hundred 
grammes.  The  average  weight  is  eleven  hundred  and  sixty 
to  thirteen  hundred  grammes. 

Microscopically,1  nerve  cell  changes  of  varying  intensity 

1  Binswanger,    Die     Pathologische    Histologie    der    Grosshirnrinden- 
Erkrankungen  bei  der  allgemeinen  progressive!!  Paralyse,  1893.     Nissl, 


282  FORMS  OF  MENTAL  DISEASE 

are  found  in  the  cortex.  None  of  these  cell  changes  are 
pathognomonic  for  paresis.  Many,  especially  the  acute  alter- 
ation (see  Plate  4,  Figure  2),  apparently  represent  a  destruc- 
tive process,  while  in  others,  as,  for  instance,  the  chronic 
change  —  cell  sclerosis  —  (see  Plate  4,  Figure  5),  the  cell 
may  persist  for  some  time.  Furthermore,  in  cells  giving 
evidence  of  sclerosis,  there  may  also  appear  evidences  of  a 
superimposed  acute  change.  The  grave  alteration  (see  Plate 
4,  Figure  3)  apparently  leads  to  absolute  destruction  of  the 
cell.  Undoubtedly  also  the  acute  and  the  chronic  changes 
can  terminate  in  a  destruction  of  the  cell.  Of  all  the  cell 
changes  only  the  acute  alteration  involves  uniformly  the 
entire  cortex.  Both  the  extent  and  the  intensity  of  the 
destructive  processes  are  apt  to  vary.  There  is  least  in- 
volvement of  the  occipital  lobe,  especially  in  the  calcarine 
area,  and  of  the  central  convolutions,  particularly  the  pre- 
central.  Furthermore,  in  a  disease  area,  normal  cells  may 
be  found  lying  side  by  side  with  altered  cells.  In  all  cases 
there  is  involvement  of  the  greater  portion  of  the  cortex,  but 
only  in  the  severe  or  prolonged  cases  are  all  of  the  cortical 
cells  diseased.  The  nerve  fibres  in  the  cortex  and  corona 
suffer  atrophy  in  proportion  to  the  extent  of  the  degenera- 
tion in  the  cortical  neurones.  Where  the  clinical  course 
has  been  prolonged  and  the  neurones  are  much  degenerated 
there  remain  but  a  very  few  normal  fibres.  Similar  de- 
struction of  the  nerve  fibres  may  be  found  in  senile  dementia 
and  epileptic  insanity,  but  it  is  not  as  far  advanced  as  in 
dementia  paralytica. 

As  the  result  of  the  degeneration  of  the  nerve  cells  and 
their  processes,  there  is  an  atrophy  of  the  cortex,  which  in 
extreme  cases  may  shrink  to  one-half  its  normal  width. 

Archiv  f.  Psy.,  Bd.  28,  S.  989.  Heilbronner,  Allgem.  Zeitschr.  f.  Psy., 
Bd.  53,  S.  172. 


Fig.  3 


Fig.  1 


Fig.  2 


Fig.  4 


Fig.  5 
Plate  4 


Fig.  6 


Fig.  1  —  Xormal  large  pyramidal  cell.  Fig.  2  —  Acute  alteration  in  dementia  para- 
lytica. Fig.  3 — Grave  alteration  in  dementia  paralytica.  Fig.  4  —  Plasma  cells 
crowded  about  a  vessel  in  dementia  paralytica.  Fig.  5  — Chronic  cell  change  in 
dementia  paralytica.    Fig.  6  —  Rod-shaped  cell  in  dementia  paralytica. 


DEMENTIA  PARALYTICA  283 

This  degeneration  may  be  more  marked  about  the  vessels. 
The  remaining  cells  are  no  longer  arranged  uniformly,  but 
are  turned  in  all  directions,  either  closely  pressed  together, 
as  seen  in  Figure  3,  Plate  5,  or  surrounded  by  areas  com- 
posed only  of  sclerotic  tissue  and  vessels  with  thickened 
walls.  Figure  3  should  be  compared  with  the  normal  cortex 
as  represented  in  Figure  2.  This  anatomical  picture  is  most 
characteristic  of  paresis.  The  cell  changes  already  described 
may  be  found  in  other  conditions,  but  in  none  do  all  the 
elements  of  the  cortex  suffer  to  such  a  profound  degree  as 
here.  In  senile  dementia,  idiocy,  and  even  in  dementia 
prsecox,  many  cells  and  fibres  are  destroyed,  but  the  general 
conformation  of  the  remaining  elements  is  undisturbed. 
This  distortion  with  the  presence  of  scar  tissue  is  present  to 
a  recognizable  extent  in  dementia  paralytica,  even  when  the 
process  is  not  far  advanced. 

In  the  areas  of  degeneration  there  may  be  a  considerable 
increase  in  the  neuroglia  tissue,  in  which  spider  cells  take  a 
prominent  part,  appearing  especially  in  the  deeper  cell 
layers  of  the  cortex  and  about  blood  vessels.  This  great 
increase  of  spider  cells  may  be  seen  in  Figures  5  and  6, 
Plate  5,  in  comparison  with  Figure  4,  which  represents  the 
neuroglia  present  in  the  normal  cortex.  The  increase  in 
neuroglia  does  not  necessarily  correspond  to  the  destruction 
of  nerve  cells,  as  normal  nerve  cells  are  often  surrounded 
by  considerable  neuroglia,  and,  on  the  other  hand,  in  some 
areas  all  the  nerve  cells  may  have  disappeared  without  an 
appreciable  increase  of  the  neuroglia. 

Vascular  lesions  in  the  cortex  form  a  prominent  part  in 
the  microscopical  picture.  The  vessels  are  increased  in 
number  and  their  walls  thickened,  as  may  be  seen  in  Plate  5, 
Figure  3.  Some  of  the  vessels  are  dilated,  a  few  totally 
obliterated,  and   others  show  small  aneurisms;  but   the 


284  FORMS  OF  MENTAL  DISEASE 

characteristic  feature  of  this  vascular  change  is  the  infiltra- 
tion of  the  perilymph  spaces  with  ordinary  lymph  cells  and 
particularly  plasma  cells  (see  Plate  4,  Figure  4),  the  latter  of 
which  may  be  regarded  as  distinctive  of  paresis,  since  they  are 
rarely  found  in  other  disease  processes.  Furthermore,  the 
prevalence  of  these  cells  stands  in  rather  definite  relationship 
to  the  extent  of  the  disease  process.  They  are  most  prevalent 
in  the  acute  stages  of  the  disease  and  later  may  disappear. 
Another  form  of  cell,  distinctive  of  paresis,  is  the  rod-shaped 
cell  first  described  by  Nissl  (see  Plate  4,  Figure  6).  The  cell 
is  long  and  narrow,  sometimes  curved,  with  a  clear  nucleus 
and  one  or  more  nucleoli.  These  cells  are  found  in  large 
numbers  mostly  in  proximity  to  blood  vessels  and  lying 
parallel  to  the  long  axis  of  the  large  nerve  cells. 

In  addition  to  the  finer  microscopic  changes  in  the  cortex, 
one  occasionally  finds  small  areas  of  softening,  which  are 
discernible  by  the  readiness  with  which  either  the  superficial 
layers  of  the  cortex  or  the  entire  cortex  are  detached  from 
the  white  matter.  Gross  focal  lesions,  such  as  one  might 
expect  to  accompany  paralytic  attacks,  are  rarely  en- 
countered. On  the  other  hand,  Lissauer,  Starlinger,  and 
others  l  have  pointed  out  that  in  the  cases  with  circum- 
scribed paralyses,  hemianopsia,  word  blindness,  and  aphasia 
there  really  are  present  corresponding  definite  circum- 
scribed disease  areas  in  the  cortex  with  recognizable 
secondary  degeneration  in  the  corona,  basal  ganglia,  pons, 
and  cord. 

The  basal  ganglia,  central  gray  matter,  and  cerebellum  also 
present  degeneration  of  the  nerve  cells  and  fibre  tracts. 
Weigert  has  demonstrated  an  increase  of  neuroglia  in  the 
granular  lajTer  of  the  cerebellum,  with  a  destruction  of  the 
Purkinje  cells  and  their  processes.    The  cranial  nerve  nuclei 

1  Starlinger,  Monatsschr.  f.  Psy.,  VII,  1 ;  Storch,  ebenda,  IX,  401. 


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Fig.  1  —  Cerebral  cortex  in  idiocy.  Fig.  2  —  Normal  cerebral  cortex.  Fig.  3  —  Cere- 
bral cortex  in  dementia  paralytica.  Fig.  4— Glia  in  normal  cerebral  cortex. 
Fig.  5  — Glosis  with  presence  of  spider  cells  in  cortex  in  dementia  paralytica. 
Fig.  fi  — Showing  the  relation  of  spider  cells  with  vessel  walls  in  deep  layers  of 
cerebral  cortex  in  dementia  paralytica. 


DEMEXTTA  PARALYTICA  285 

of  the  medulla  show  similar  changes  to  those  seen  in  the 
cortical  cells. 

The  spinal  cord  1  is  involved  to  a  greater  or  less  extent  in 
almost  all  cases,  the  most  important  lesion  being  degenera- 
tion of  the  fibre  tracts  in  the  posterior  and  lateral  columns. 
Degenerative  changes  are  occasionally  found  in  the  pe- 
ripheral nerves.  In  the  internal  organs  vascular  changes 
are  so  frequently  found  that  they  seem  to  bear  a  definite 
relationship  to  the  disease  process.  Of  these,  atheroma  of 
the  aorta  and  arteritis  of  the  vessels  of  the  fiver  and  kidneys 
are  the  most  prominent. 

Symptomatology.  —  From  the  onset  of  the  disease  there  is 
increasing  difficulty  of  apprehension  of  external  impressions. 
Patients  are  unable  to  grasp  clearly  and  sharply  the  char- 
acter of  the  environment.  Later  they  mistake  persons,  fail 
to  recognize  former  well-known  objects,  and  overlook  im- 
portant details.  Attention  is  maintained  with  effort.  Long 
and  complicated  sentences  are  not  comprehended,  and  they 
often  miss  the  connection  of  things.  Customary  duties  are 
performed  with  difficulty  and  often  incorrectly.  Thus,  there 
develops  a  clouding  of  consciousness;  the  patients  live  a  dreamy 
existence,  as  if  constantly  under  the  influence  of  liquor. 
This  condition  of  torpor  is  an  important  diagnostic  sign.  Later 
the  disorientation  increases.  The  patients  may  answer  ques- 
tions quite  correctly  and  upon  superficial  examination  seem  to 
conduct  themselves  in  accord  with  their  environment;  but 
at  the  same  time  they  neither  know  where  they  are,  with 
whom  they  are  speaking,  nor  the  significance  of  what  is 
taking  place  about  them.  They  fail  to  recognize  the  season 
or  the  time  of  day.     A  patient  may  say  that  it  is  summer 

1  Westphal,  Allgem.  Zeitschr.  f.  Psy.,  Bd.  20-21.  Westphal,  Archiv 
f.  Psy.,  H.  I.,  Bd.  12.  Westphal,  Virchow's  Archiv,  Bd.  39.  Fuestner, 
Archiv  f.  Psy.,  Bd.  24. 1. 


286  FORMS  OF  MENTAL  DISEASE 

while  leaning  upon  a  hot  radiator  and  looking  out  upon  a 
snow-covered  landscape.  This  condition  finally  reaches  one 
of  absolute  disorientation,  when  the  patients  cannot  perceive 
or  elaborate  any  external  impressions. 

At  the  onset  of  the  disease  there  is  usually  an  increase  of 
the  sense  of  fatigue.  The  patients  tire  easily  at  their  ac- 
customed duties  and  require  more  frequent  and  longer 
periods  of  rest.  Hallucinations  play  an  unimportant  part. 
In  the  greater  number  of  cases  none  appear,  but  in  some 
cases  there  exist  for  some  time  very  many  hallucinations  of 
all  senses.  Again  the  clinical  picture  may  be  very  like  that 
of  the  acute  alcoholic  hallucinosis.  Hallucinations  of  sight 
are  often  present  in  patients  with  optic  atrophy.  Hallucina- 
tions of  touch  in  connection  with  delusions  of  influence  are 
not  infrequent. 

The  defects  of  memory  are  very  characteristic  and  are 
among  the  most  prominent  of  the  mental  symptoms.  The 
memory  at  first  becomes  defective  for  recent  and  passing 
events.  This  defect  is  sometimes  keenly  appreciated  by 
the  patients,  who  complain  of  and  sometimes  devise  means 
for  correcting  it.  Later,  memory  becomes  progressively 
more  defective.  The  memory  is  especially  defective  in  the 
temporal  arrangement  of  experience,  and  the  patients  fail 
to  recall  the  time  of  the  occurrence  of  events.  They  cannot 
inform  you  when  the  mail  arrived,  when  they  had  breakfast, 
or  when  they  last  saw  you.  These  patients  may  live  so 
completely  in  the  present  moment  that  they  may  ask  several 
times  a  day  where  they  are,  how  long  they  have  been  there, 
or  if  they  have  ever  seen  you  before.  The  early  events  of 
life  are  comparatively  well  retained  for  some  time,  the 
patients  being  able  to  tell  of  their  occupation,  former  places 
of  residence,  and  events  of  their  childhood,.  This  remote 
memory  also  suffers  late  in  the  disease,  and  here  also  the 


DEMENTIA  PARALYTICA  287 

time  element  is  the  first  to  be  affected.  Dates  of  marriage, 
births  of  children,  and  important  events  are  completely  for- 
gotten. Finally  they  are  unable  to  recall  the  place  of  birth 
and  even  the  names  of  their  parents  and  children.  Lapses 
of  memory,  when  definite  periods  of  time  are  completely 
forgotten,  may  occur  following  epileptiform  or  apoplecti- 
form seizures. 

The  store  of  ideas  undergoes  a  progressive  impoverishment, 
terminating  in  a  complete  destruction  of  all  the  mental 
possessions.  The  rapidity  of  this  process  varies  with  the 
intensity  of  the  disease  and  the  power  of  resistance  as  well 
as  the  intelligence  of  the  individual.  The  more  intelligent 
resist  longer,  and  the  most  frequented  paths  of  thought  are 
retained  longest.  As  memory  fails,  its  place  in  the  intel- 
lectual life  is  often  made  good  by  the  imagination.  As  real 
reminiscences  disappear,  invention  runs  riot.  Whatever 
enters  the  mind  is  related  as  genuine;  stories,  or  what  may 
have  been  told  them  by  another,  become  a  part  of  their  own 
experience.  The  patient  relates  that  he  was  in  a  terrible 
railroad  accident  last  night,  in  which  a  dozen  were  killed; 
he  led  the  troops  at  San  Juan;  yesterday  he  had  a  conference 
with  the  British  ambassador.  He  has  captured  a  hundred 
beautiful  women  from  a  Turkish  harem,  and  discovered  a 
new  and  inexpensive  motive  power  for  automobiles.  These 
dreamlike  fabrications  are  most  pronounced  in  cases  of 
optic  atrophy.  Very  often  such  fabrications  are  used  in 
filling  in  the  gaps  in  recent  memory.  They  can  be  brought 
out  and  influenced  by  suggestion  on  the  part  of  the  listener. 
The  patient  may  be  somewhat  dubious  at  first  when  express- 
ing these  absurd  reminiscences,  but  at  the  next  interview 
all  doubt  will  have  disappeared.  This  susceptibility  of  the 
memory  to  external  influences  is  a  part  of  the  general 
susceptibility  of   thought   of   the   patients.     Their  ideas 


288  FORMS  OF  MENTAL  DISEASE 

are  never  firmly  grounded,  and  fail  to  exert  a  lasting  influ- 
ence upon  their  thoughts  and  actions.  Any  accidental 
impulse  suffices  to  distract  and  lead  them  into  another 
channel. 

Impairment  of  judgment  is  another  very  prominent  symp- 
tom. It  may  be  the  first  to  call  attention  to  the  disease. 
Objects  of  former  criticism  now  fail  to  arouse  comment. 
The  former  conservative  principles  which  have  made  their 
business  life  a  success  are  lost  sight  of,  and  new  plans  lack 
unity  and  system.  Weighty  obstacles  are  overlooked  and 
senseless  schemes  produced  with  perfect  serenity.  Business 
and  social  standards  are  completely  disregarded.  Their 
conceptions  have  no  bearing  upon  the  environment,  but 
center  almost  entirely  about  themselves,  so  that  they  come 
to  live  in  a  sort  of  dream  world,  in  which  everything  depends 
upon  their  own  ideas  and  wishes.  The  formation  of  delu- 
sions, which  partially  results  from  this  defect  of  judgment, 
varies  much  in  different  cases.  In  some  there  are  but  few 
delusions,  but  in  most  cases  the  delusions  form  a  prominent 
feature  in  the  early  stages  of  the  disease.  These  delusions 
are  transitory,  unstable,  without  system,  and  show  confusion 
and  incoherence.  They  are  characterized  by  vagaries,  sense- 
lessness, numerous  variations,  and  contradictions.  It  only 
rarely  happens  that  for  short  periods  the  delusions  are 
stable  and  uniform  like  those  of  paranoia. 

It  is  not  unusual  at  the  onset  for  the  patients  to  express 
some  insight  into  their  mental  disease,  complaining  of  their 
failing  memory,  irritability,  and  increasing  difficulty  of 
thought.  Later,  with  increasing  deterioration,  all  genuine 
insight  disappears.  The  patients  then  usually  exhibit  a  feel- 
ing of  well-being;  they  claim  that  they  never  felt  stronger 
or  more  vigorous  mentally.  At  times  during  the  course  of 
the  disease  the  patients  may  make  various  hypochondriacal 


DEMENTIA  PARALYTICA  289 

complaints,  but  even  then  they  fail  to  recognize  the  real 
physical  symptoms  of  the  disease. 

The  emotional  life  shows  a  profound  disturbance.  At 
first  there  is  usually  increased  irritability.  The  patients  are 
easily  disturbed  at  home  and  work,  are  sullen,  peevish,  and 
apt  to  show  considerable  passion  at  trifling  annoyances,  and 
completely  lose  control  of  themselves.  On  the  other  hand, 
they  may  show  an  unusual  insensibility  to  the  claims 
of  others,  indicative  of  the  deterioration  of  the  finer  feelings. 
They  then  fail  to  show  sympathy  at  the  suffering  of  their 
children,  are  indifferent  to  immoral  surroundings,  and  do 
not  take  their  wonted  pleasure  in  reading  or  professional 
pursuits. 

The  emotional  attitude  is  much  in  accord  with  the  char- 
acter of  the  delusions;  it  is  elated  with  expansive,  or  dejected 
with  depressing  delusions.  Later  the  emotional  tone  be- 
comes very  unstable,  and  there  are  frequent  and  abrupt 
changes.  In  the  midst  of  laughter  they  may  break  out  in 
a  storm  of  tears,  or  misery  may  give  way  to  silly  happiness. 
These  changes  of  emotion  may  be  brought  by  simple  sug- 
gestions or  by  raising  or  lowering  the  tone  of  voice,  or  even 
by  the  expression  of  the  face.  A  patient  lying  on  the  floor, 
complaining  that  he  had  lost  all  his  organs,  that  he  had  no 
blood  and  could  not  breathe,  when  tickled  in  the  ribs  and 
asked  how  he  felt,  exclaimed,  beginning  to  laugh,  "  I  am 
feeling  fine;  come  and  see  me  again."  In  the  demented 
forms  of  the  disease,  where  there  may  be  only  a  few  delu- 
sions, no  especial  emotions  are  shown,  the  patients  being  in 
a  condition  of  simple  joy  or  irritable  dissatisfaction  most  of 
the  time. 

There  is  a  profound  change  of  disposition;  the  former 
stability  and  independence  of  action  give  way  to  progres- 
sive weakness  of  the  will  power.    The  patients  become  very 


290  FORMS  OF  MENTAL  DISEASE 

tractable,  but  occasionally  may  be  extremely  stubborn. 
Early  in  the  disease  they  are  led  to  indulge  in  all  sorts  of 
excesses  and  sometimes  persuaded  to  deed  away  property. 
When  angered  and  determined  to  commit  an  assault  upon 
some  one,  they  may  be  easily  influenced  to  desist  by  a  simple 
suggestion.  A  patient  about  to  leap  from  a  third-story 
window  because  of  fear,  was  readily  prevented  by  the  sug- 
gestion that  it  would  be  better  to  go  down  and  jump  up. 
Any  impulse  that  arises  may  be  acted  upon  without  refer- 
ence to  the  extreme  difficulty  of  its  accomplishment.  One 
patient  is  said  to  have  stepped  out  from  a  second-story 
window  for  the  purpose  of  picking  up  a  cigar  stump. 

In  conduct,  the  patients  show  a  disregard  for  the  demands 
of  custom  and  law,  are  unconstrained,  and  often  commit 
grave  offences  into  which  they  have  no  insight.  As  a  reason 
for  such  conduct,  they  often  say  that  they  acted  so  because 
it  happened  to  come  into  their  minds.  The  social  re- 
straints normally  imposed  upon  one  by  the  environment 
never  interfere  with  the  carrying  out  of  their  wishes.  They 
are  quite  reckless  of  personal  safety,  and  occasionally  injure 
themselves  severely  in  their  foolhardy  actions.  In  condi- 
tions of  great  clouding  of  consciousness  or  in  advanced 
deterioration  there  are  sometimes  present  some  symptoms 
characteristic  of  the  catatonic  form  of  dementia  prsecox, 
such  as  catalepsy,  verbigeration,  negativism,  and  stereo- 
typed movements;  but  these  are  transitory  and  change 
more  readily  and  frequently  than  in  catatonia. 

Physical  Symptoms.  — ■  The  physical  signs  of  the  disease, 
in  both  the  motor  and  the  sensory  fields,  are  as  extensive 
and  profound  as  the  psychical.  These  may  appear  either 
before  the  mental  symptoms  or  not  until  dementia  has 
become  well  advanced;  usually  they  are  coincident. 

Of  the  sensory  symptoms,  headache  is  often  the  first  to 


DEMENTIA  PARALYTICA  291 

appear,  accompanied  by  a  feeling  of  pressure  as  if  the  head 
were  being  held  in  a  vice,  together  with  ringing  in  the  ears 
and  dizziness.  The  special  senses  at  first  give  evidence  of 
excitation,  which  later  subsides  into  a  state  of  insensibility 
corresponding  closely  in  degree  to  the  stage  of  deterioration. 
Some  patients  have  difficulty  in  the  recognition  and  localiza- 
tion of  objects  held  before  them,  which  by  Fuerstner  is 
ascribed  to  involvement  of  the  occipital  cortex.  Word 
blindness  and  asymbolism  are  often  observed.  Hemia- 
nopsia occasionally  follows  apoplectiform  or  epileptiform 
attacks.  Optic  atrophy  is  found  in  five  to  twelve  per  cent, 
of  the  cases.  Disturbances  of  the  senses  of  taste  and  smell 
have  also  been  observed  by  some,  especially  the  loss  of  the 
sense  of  taste  for  saline  solutions.  The  disturbance  of  the 
cutaneous  sensations  is  quite  often  prominent ;  at  first  there 
may  be  all  sorts  of  uncomfortable  sensations,  burning  or 
drawing  sensations,  rheumatic  pains,  etc.  Hence,  many 
patients  are  for  a  long  time  regarded  as  neurastheniacs.  In 
some  cases  there  is  an  increased  sensitiveness  to  cold.  Later 
analgesia  appears,  which  may  be  so  pronounced  that  needles 
can  be  thrust  entirely  through  a  limb  without  pain. 
Finally,  the  patients  may  pull  out  their  hair,  disturb  an 
open  wound,  draw  out  their  toe-nails,  and  persist  in  mangling 
their  own  flesh. 

Of  the  motor  symptoms  paralytic  attacks,  mostly  epilepti- 
form or  apoplectiform,  are  very  important,  occurring  in 
from  forty-six  to  sixty  per  cent,  of  cases.  The  attacks  may 
be  very  light,  consisting  only  of  a  transitory  dizziness  with 
perhaps  an  inability  to  speak.  Attacks  of  this  sort  are 
often  the  first  symptoms  to  call  attention  to  the  disease. 
Occasionally  the  attack  consists  of  a  suddenly  developing 
aphasia  lasting  several  days,  unaccompanied  by  paralysis. 
In  the  epileptiform  attacks,  which  may  be  either  of  the 


292  FORMS  OF  MENTAL  DISEASE 

Jacksonian  or  of  the  ordinary  type,  confusion  or  stupidity 
may  usher  in  the  attacks,  which  begin  with  a  fall  to  the 
floor,  loss  of  consciousness,  and  convulsive  movements, 
usually  in  one  limb,  extending  gradually  to  the  others. 
Clonic  movements  predominate  and  are  often  synchronous 
with  the  pulse.  Convulsive  movements  may  be  confined  to 
a  single  group  of  muscles  or  to  one  limb.  The  duration  of 
the  attack  is  from  one  to  several  hours,  but  sometimes 
clonic  movements  of  varying  intensity  continue  in  one  or 
more  limbs  for  days.  A  condition  similar  to  status  epilepti- 
cus,  where  there  are  from  twenty  to  one  hundred  attacks 
daily,  may  persist  for  days,  often  terminating  in  death. 
During  the  attacks  the  temperature  is  often  febrile,  the 
urine  frequently  contains  albumen,  and  there  may  be  reten- 
tion of  urine  and  feces,  as  well  as  paralysis  of  the  muscles  of 
deglutition.  The  fatal  termination  is  usually  due  to  aspira- 
tion pneumonia.  The  attacks  pass  off  slowly,  sometimes 
leaving  the  patients  in  a  condition  of  confusion.  In  the 
earlier  stages  of  the  psychosis,  these  attacks  leave  the 
patients  in  a  condition  of  more  profound  deterioration,  and 
sometimes  also  with  signs  of  transient  aphasia,  hemiplegia, 
hemianopsia,  convulsive  movements,  or  areas  of  anaesthesia. 
Apoplectiform  attacks  often  occur,  and  may  be  the  first 
important  sign  of  the  disease.  In  these  attacks  there  is 
the  usual  loss  of  consciousness  and  stertorous  breathing, 
with  occasional  high  elevation  of  temperature,  accompanied 
by  hemiplegia  and  aphasia.  In  some  attacks  there  is  no 
loss  of  consciousness,  simply  the  sudden  appearance  of 
transitory  paralysis.  Transitory  sensory  disturbances  can 
similarly  appear;  as,  severe  paresthesias,  anaesthesias,  or 
defects  of  vision.  It  is  a  distinguishing  feature  of  these 
apoplectiform  attacks  that  the  paralysis  disappears  quickly 
and  without  evident  residuals.     Other  somewhat  similar 


DEMENTIA  PARALYTICA  293 

attacks,  occurring  in  the  course  of  the  disease,  are  those  in 
which  there  is  a  sudden  development  of  extreme  confusion, 
with  motor  restlessness,  difficult  speech,  flushing  of  the  face 
and  body,  vomiting,  and  high  temperature.  These  last  from 
a  few  hours  to  a  few  days  and  pass  away  quickly,  leaving  the 
patient  in  his  former  state. 

The  frequency  of  the  apoplectiform  and  epileptiform 
attacks  depends  somewhat  upon  the  character  of  the  treat- 
ment. They  may  result  from  emotional  disturbances,  ex- 
cesses in  eating,  and  especially  from  an  accumulation  of  feces 
in  the  rectum,  but  they  frequently  appear  without  evident 
cause.  Bed  treatment,  regularly,  reduces  their  frequency. 
They  occur  most  often  in  the  demented  form  of  the  disease. 

Motor  disturbances  of  the  eye  include  transitory  paralysis 
of  single  muscles  (eighteen  per  cent,  of  the  cases)  and  rarely 
complete  ophthalmoplegia.  Differences  of  the  pupil  occur 
in  about  fifty-seven  to  eighty-three  per  cent,  of  the  cases, 
immobile  pupils  in  from  thirty-four  to  sixty-eight  per  cent., 
and  sluggish  reaction  to  light  in  thirty-five  and  five-tenths 
per  cent.  (Argyll-Robertson  pupil). 

The  muscles  of  the  face  lose  their  tone,  the  nasolabial  fold 
and  other  lines  of  expression  disappear,  and  the  countenance 
becomes  expressionless.  This  washed-out,  expressionless 
character  of  the  countenance  is  well  represented  by  the 
group  of  three  paretics  seen  in  Plate  6.  Lack  of  tone  in  the 
muscular  system  is  also  seen  in  their  slouching  and  inelastic 
attitude.  There  is  also  a  loss  of  control  of  the  muscles, 
giving  rise  to  incoordination,  noticeable  mostly  when  the 
mouth  or  eyes  are  forcibly  opened.  A  fine  tremor  of  these 
muscles  is  almost  always  present.  The  voice  loses  its  char- 
acteristic tone  and  becomes  monotonous.  Tremor  of  the 
tongue,  which  may  be  either  finely  fibrillary  or  coarse  and 
retractive,  is  a  constant  sign.     In  advanced  cases  there  is 


294  FORMS  OF  MENTAL  DISEASE 

often  a  rolling  of  the  tongue  about  the  mouth  as  if  it  were  a 
quid.  This  in  some  cases  has  been  explained  by  the  presence 
of  areas  of  anaesthesia  in  the  mucous  membrane.  Gritting 
of  the  teeth  is  occasionally  associated  with  these  movements 
of  the  tongue,  or  may  be  present  alone. 

Disturbances  of  speech  are  among  the  most  characteristic 
symptoms.  They  are  either  aphasic  or  articulatory. 
Transitory  aphasia  often  appears  after  paralytic  attacks. 
Paraphasia,  which  may  appear  at  the  same  time,  is  more  per- 
sistent and  sometimes  lasts  several  months.  Word  blindness 
and  word  deafness  are  rarely  encountered.  There  is  occa- 
sionally agrammatism,  as  seen  in  the  misuse  of  infinitives 
and  omission  of  conjunctions.  There  may  be  an  elision  of 
syllables,  as  in  the  use  of  elexity  for  electricity,  or  a  redu- 
plication of  syllables,  as  electricicity,  and  finally  there  may 
be  tendency  to  repeat  syllables,  forming  a  genuine  word 
clonus,  as  Massachusetts-etts-etts-etts. 

Disturbances  of  articulation  are  more  frequent.  They 
may  follow  paralytic  attacks,  but  more  often  occur  in- 
dependently of  them.  As  the  result  of  difficulty  in  move- 
ment of  the  lips  and  tongue  frequent  pauses  are  made 
between  syllables  or  words  —  hesitating  speech  —  and  when 
accompanied  by  a  fall  in  the  tone  of  voice  produce  a  scanning 
speech.  Gliding  over  the  poorly  articulated  sounds  gives 
rise  to  an  indistinct  and  slurring  speech.  These  difficulties 
lead  to  the  substitution  of  words  or  syllables  similar  in 
sound  but  more  easily  pronounced,  or  to  the  elision  of  diffi- 
cult syllables.  Many  patients,  in  their  efforts  to  overcome 
these  difficulties,  stutter  and  produce  an  explosive  speech. 
The  patients  often  appreciate  the  difficulties  of  speech,  but 
are  ready  to  explain  them  by  dryness  of  the  mouth  or  loss 
of  teeth.  Speech  disturbances  are  readily  observed  in 
ordinary  conversation.    The  test  words  and  phrases,  if  used, 


DEMENTIA  PARALYTICA  295 

should  be  introduced  into  long  sentences,  because,  if  the 
attention  is  concentrated  upon  single  words,  they  may  be 
pronounced  correctly.  Words  and  phrases  used  for  this 
purpose  are:  electricity,  national  intelligency,  methodist 
episcopal,  ninth  riding  Massachusetts  artillery  brigade,  etc. 

The  central  and  ataxic  speech  disturbances  are  best 
elicited  by  asking  the  patients  to  read  aloud.  Writing 
usually  shows  defects  similar  to  those  noticed  in  speech,  but 
they  are  proportionately  more  prominent  (Plates  7  and  8). 
Patients,  on  the  other  hand,  who  speak  clearly  may  produce 
on  paper  an  unintelligible  muddle  of  words  and  syllables. 
In  advanced  cases  there  is  complete  agraphia  (Plate  7,  Fig- 
ures 2  and  3).  The  patients  are  then  able  to  make  but  a  few 
unintelligible  marks,  and  may  even  give  up  without  making 
a  sign.  The  handwriting  is  characterized  by  irregularities 
caused  by  the  tremor,  excessive  pressure  on  the  pen,  and 
carelessness.  The  irregularities  are  more  extensive  than  in 
the  case  of  the  senile,  whose  lines  show  the  effect  of  a  fine 
regular  tremor. 

Ataxia  appears  first  of  all  in  those  finer  movements  such 
as  are  employed  by  skilled  workmen.  Later  the  more 
delicate  movements  in  locomotion,  such  as  turning  about 
quickly,  become  ataxic.  The  clothing  cannot  be  readily 
buttoned,  the  gait  becomes  unsteady,  swaying  and  shuffling. 
In  from  sixteen  to  twenty-four  per  cent,  of  the  cases  of 
paresis  there  are  tabetic  signs;  such  as,  loss  of  reflexes, 
ataxia,  Romberg  sign,  paralysis  of  the  rectum  and  bladder, 
and  occasionally  girdle  symptoms,  lancinating  pains,  and 
crises.  In  from  six  to  eight  per  cent,  of  cases,  genuine  tabes 
antedates  for  several  years  the  appearance  of  the  paretic 
symptoms   (ascending  paresis  or  tabo-paresis)}    In  about 

1  Cotton,  Amer.  Jour,  of  Insanity,  Vol.  61,  p.  581.  Gaupp,  Uber 
die  spinalen  Symptome  der  progressiven  Paralyse,  1898.    Torkel,  Besteht 


296  FORMS  OF  MENTAL  DISEASE 

fourteen  per  cent,  of  the  cases  of  paresis  there  are  evidences 
of  involvement  of  the  lateral  column  of  the  cord,  as  shown 
by  the  spastic  paralyses.  In  many  cases  spastic  and  tabetic 
symptoms  are  variously  combined.  Intention  tremor  may 
be  present,  and  in  a  few  cases  choreiform  movements  are 
marked  enough  to  simulate  Huntingdon's  chorea.  Later  in 
the  course  of  the  disease  the  patients  become  bedridden 
and  often  develop  contractures  and  muscular  atrophy.  The 
body  also  tends  to  assume  a  curved  position  with  a  fixed  ten- 
sion of  the  muscles  of  the  neck  so  that  the  head  is  thrown 
forward  and  the  body  does  not  rest  upon  the  bed  through- 
out its  entire  length.  During  this  stage  of  the  disease 
there  is  occasionally  noticed  convulsive  movements  of  the 
individual  muscle  groups,  especially  during  active  and  pas- 
sive movements,  but  also  when  the  muscles  are  at  rest. 

The  pressure  of  the  spinal  fluid,  according  to  Schaefer,1 
is  increased  in  two-thirds  of  the  cases  from  normal  (40  to 
70  millimetres)  to  150-380  millimetres.  Furthermore,  he 
finds  that  the  albumen  is  increased  and  contains  serum  al- 
bumin, while  the  normal  fluid  contains  only  globulin.  The 
microscopical  examination  of  fluid  shows  a  lymphocytosis 
(see  p.  103).  The  tendon  reflexes  are  usually  exaggerated, 
sometimes  so  markedly  that  the  entire  body  shakes  when  the 
tendon  is  struck.  Frequently  the  exaggeration  diminishes, 
and  in  twenty  to  thirty  per  cent,  of  the  advanced  cases  the 
reflexes  are  lost.  In  eighteen  per  cent,  of  the  cases  there  is 
a  difference  in  the  two  sides.  The  loss  of  the  patellar  reflexes 
is  usually  associated  with  immobile  pupils  and  myosis.  The 
Babinski  reflex  is  often  elicited  in  connection  with  spastic 

eine  gesetzmassige  Verschiedenheit  in  Verlaufsart  und  Dauer  d.  progres- 
siven  Paralyse  nach  d.  Charakter  d.  begleitenden  Rmaffektion  ?  Diss., 
Marburg,  1903. 

1  Schaefer,  Allgem.  Zeitschr.  f.  Psy.,  LIX,  84. 


Fig.  1 


<rWj& 


H- 


Fig.  2 


Plate  7 

Fig.  1  shows,  besides  the  excessive  pressure  elision,  substitution  of  letters  and  sylla- 
bles. The  patient  has  attempted  to  write  from  dictation,  "  Around  the  rugged 
rock  the  ragged  rascal  ran." 

Figs.  2  and  3  represent  conditions  which  approach  complete  agraphia,  in  which  the 
patients,  after  an  attempt  to  write,  simply  laid  the  pen  down. 


DEMENTIA  PARALYTICA  297 

symptoms.  The  electrical  irritability  of  the  muscles  is  in- 
creased at  first,  but  later  diminished.  Disturbances  of  the 
bladder  are  often  present,  both  retention  and  incontinence, 
the  latter  usually  being  the  result  of  the  former.  Sluggish- 
ness of  the  bowels  may  extend  to  obstinate  constipation. 
Finally  in  the  end  stages  there  is  paralysis  of  both  sphincters. 
The  sexual  power  may  be  increased  at  the  onset,  but  later 
it  is  diminished.  The  vasomotor  disturbances  consist  of 
erythema,  persistent  blushing  of  the  skin,  rush  of  blood  to 
the  head,  dermographia,  and  cyanosis.  The  so-called  trophic 
changes,  acute  decubitus,  increased  fragility  of  the  ribs, 
and  othematoma,  stand  in  close  relation  to  the  vasomotor 
changes,  and  are  of  frequent  occurrence.  Furthermore, 
there  is  a  loss  of  vitality  and  of  the  power  of  repair  in  all 
tissues,  so  that  a  very  trifling  injury  may  lead  to  an  extensive 
lesion.    Acute  decubitus  once  started  is  difficult  to  heal. 

The  temperature  during  the  course  of  the  disease  is  mostly 
normal,  except  toward  the  end,  when  it  is  apt  to  be  sub- 
normal. A  striking  peculiarity  is  the  excessive  elevation  of 
temperature  with  trifling  disturbances,  such  as  mild  bron- 
chitis, overdistention  of  the  bladder,  or  obstinate  constipa- 
tion. There  is  often  a  rise  of  temperature  during  paralytic 
attacks,  and  finally,  as  already  mentioned,  there  may  be 
short  periods  of  a  few  hours  or  more  of  an  excessively  high 
temperature  apparently  without  adequate  cause. 

The  sleep  is  usually  somewhat  disturbed  during  the  first 
stage  and  more  so  during  the  second,  where  there  is  motor 
excitement,  but  in  the  last  stage  the  patients  are  sluggish 
and  may  sleep  much  of  the  time.  This  varies,  however,  as 
in  some  cases  the  patients  may,  from  the  onset,  show  a 
tendency  to  sleep  continually,  while  in  other  cases  insomnia 
persists  throughout  the  whole  course.  The  appetite  suffers 
at  first  and  during  excitement,  but  later  the  patients  eat 


298  FORMS  OF  MENTAL  DISEASE 

well.  The  condition  of  nutrition  is  poor  until  excitement 
subsides  and  deterioration  is  well  advanced,  when  there  is 
usually  an  increase  in  weight,  which  may  last  until  death. 
Sometimes  loss  of  appetite  and  impaired  nutrition  coexist, 
leading  to  extreme  emaciation.  Occasionally  albumen  and 
sugar  are  present  in  the  urine.  The  blood  changes  l  consist 
of  a  moderate  and  progressive  anaemia,  in  which  the  fall  in 
haemoglobin  is  most  marked,  a  progressive  increase  of  the 
polymorphoneuclear  leucocytes  reaching  its  highest  point 
during  the  terminal  state,  and  a  transitory  leucocytosis 
accompanying  paralytic  attacks.  D'Abundo  has  called 
attention  to  an  increased  toxicity  of  the  blood,  and  Idelsohn  2 
finds  that  the  blood  of  paretics  in  a  considerable  proportion 
of  cases  inhibits  or  prevents  the  growth  of  cultures  of 
bacteria. 

The  mental  and  physical  symptoms  enumerated  above 
represent  in  general  the  clinical  picture.  The  grouping  of 
the  individual  symptoms,  however,  varies  widely  in  different 
cases.  This  has  led  to  the  recognition  of  four  types  of  cases : 
the  demented,  expansive,  agitated,  and  depressive,  each  of 
which  presents  a  somewhat  different  course  from  the  onset. 
The  deviations  from  these  types  deter  many  from  the 
acceptance  of  this  differentiation,  but  its  value  becomes 
apparent  in  a  considerable  number  of  cases  where  one  is 
able  to  forecast  the  future  duration  of  the  disease  and  the 
character  of  many  of  the  symptoms. 

The  demented  form,  because  of  the  simple  deterioration, 
unaccompanied  by  many  delusions  and  hallucinations,  its 
rapid  course  without  remissions,  and  the  relative  frequency 
of  its  occurrence  should  be  regarded  as  the  type  of  the 

1  Diefendorf,  Amer.  Jour.  Med.  Sciences,  Vol.  126,  p.  1047.  Capps, 
Amer.  Jour.  Med.  Sc,  1897. 

2  Idelsohn,  Archiv  f.  Psy.,  XXXI,  64a 


e3     5 


2  c 


2  2 


DEMENTIA  PARALYTICA  299 

disease.  The  clinical  picture  of  megalomania,  which  has 
been  and  still  is,  by  some,  regarded  as  the  prototype  of  the 
disease,  has  in  recent  years  become  less  and  less  prominent, 
until  it  is  now  encountered  in  less  than  twenty-five  per  cent, 
of  cases. 

Demented  Form 

The  demented  form  is  characterized  by  gradually  progres- 
sive mental  deterioration  without  prominence  of  either  hallucina- 
tions, delusions,  or  great  psychomotor  disturbance.  Transitory 
periods  of  delirious  excitement,  of  anxious  unrest  with  hypo- 
chondriacal ideas  of  depression,  delusional  states,  or  periods 
of  megalomania  may  occur  in  this  picture,  but  they  are  in- 
significant when  compared  with  the  rapid  advance  of  pro- 
found deterioration. 

The  onset  of  this  form  is  very  gradual.  The  symptoms  at 
first  may  resemble  those  of  neurasthenia ;  patients  complain 
of  inability  to  apply  themselves  to  work,  loss  of  energy, 
indefinite  pains,  feeling  of  pressure  in  the  head,  and  irri- 
tability. They  are  forgetful  and  flighty,  at  times  drowsy, 
and  at  others  somewhat  confused.  Soon  mental  deteriora- 
tion becomes  apparent  in  the  inability  to  explain  their 
actions,  in  errors  of  judgment,  failure  of  memory,  and 
absence  of  the  usual  moral  feelings.  Their  work  is  irksome, 
and  they  occasionally  fall  asleep  over  it.  They  forget  to 
go  to  meals,  make  mistakes  in  figures,  and  overlook  im- 
portant matters.  They  are  usually  good-natured,  tractable, 
are  easily  led  astray,  and  often  drink  to  intoxication.  In 
some  cases,  however,  they  become  obstinate  and  self-willed. 
The  household  suffers,  dinner  is  uncooked  or  improperly 
seasoned,  and  the  children  are  neglected.  Patients  are 
reckless  and  may  even  act  in  opposition  to  established  pre- 
cepts.    The  consciousness  soon  becomes  clouded  and  the 


300  FORMS  OF  MENTAL  DISEASE 

patients  fail  to  thoroughly  comprehend  their  environment, 
lose  account  of  time,  get  confused  as  to  place,  and  mistake 
persons.  They  may  even  get  confused  in  their  own  home 
and  not  recognize  friends  and  relatives. 

Transitory  hallucinations  and  delusions  may  appear,  but 
the  latter  are  very  weak,  childish,  and  easily  influenced  by 
suggestion.  Occasionally  there  are  weak  attempts  at  fabri- 
cation. During  the  early  stages  there  may  be  some  anxiety 
with  weeping  and  praying,  and  frequently  also  an  increased 
irritability,  some  sexual  excitement,  aggressiveness,  and 
assaults;  but  the  characteristic  emotional  change  is  a  pro- 
gressive deterioration  of  the  feelings.  The  patients  become 
increasingly  dull  and  apathetic.  They  are  perfectly  con- 
tented wherever  placed  as  long  as  the  simplest  needs  are 
satisfied;  such  as,  food,  drink,  and  tobacco.  They  have  a 
complacent  smile  when  addressed,  greet  strangers  very 
cordially,  and  are  friendly  with  every  one.  Often  at  first 
there  is  some  insight,  when  the  patients  complain  of  slow- 
ness of  thought  and  failure  of  memory,  but  the  increasing 
deterioration  obscures  this  feeble  capacity.  On  the  other 
hand,  they  may  express  a  feeling  of  well-being  and  perfect 
confidence  in  their  business  capacity. 

The  capacity  for  work  suffers  soon.  The  patients  become 
careless  in  their  duties,  forget  engagements,  allow  letters  to 
go  unanswered,  go  to  work  at  all  hours,  and  finally  stay 
away  altogether.  A  few  patients  may  struggle  along  with 
their  work,  realizing  and  worrying  over  difficulties  and  fre- 
quent eiTors,  while  others  neglect  their  occupation  to  look 
after  all  sorts  of  unnecessary  and  unprofitable  affairs.  They 
may  become  restless,  wandering  aimlessly  about,  indulging 
in  excesses  or  committing  petty  crimes.  They  lack  will 
power,  are  easily  led  astray,  are  unable  to  care  for  them- 
selves, forget  when  to  go  to  meals,  and  neglect  their  per- 


DEMENTIA  PARALYTICA  301 

sonal  appearance.  On  the  contrary,  some  patients  are 
inaccessible,  repulsive,  and  surly,  answering  questions  as 
if  angry,  rebuffing  friendly  advances,  and  opposing  without 
reason  anything  desired  of  them. 

A  few  patients,  in  spite  of  an  advanced  stage  of  deteriora- 
tion, present  a  good  demeanor.  They  greet  one  correctly, 
and  appear  perfectly  at  ease  in  talking  about  themselves, 
but  at  the  same  time  are  disoriented,  and  are  unable  to  give 
any  coherent  account  of  their  lives.  The  patients  usually 
enjoy  a  good  appetite,  sleep  well,  and  are  the  picture  of 
health.  The  mental  deterioration  may  have  been  so  gradual 
and  so  unobtrusive  that  the  friends  and  relatives  fail  to 
appreciate  the  profound  degree  of  deterioration  exhibited. 

This  form  of  dementia  paralytica  embraces  forty  per  cent, 
of  the  cases  admitted  to  institutions.  Paralytic  attacks 
occur  in  almost  one-half  of  the  cases.  Remissions  are  less 
frequent  than  in  the  other  forms.  The  duration  in  almost 
half  of  the  cases  does  not  extend  beyond  two  years.  In 
eighteen  per  cent,  of  the  cases  death  ensues  within  the  first 
year,  and  it  is  very  rare  that  the  disease  lasts  five  years. 

Expansive  Form 

The  expansive  form  is  characterized  by  great  prominence 
of  expansive  delusions,  a  prolonged  course,  and  greater 
prevalence  of  remissions. 

The  onset  is  usually  gradual,  with  change  of  character, 
difficulty  of  mental  application,  signs  of  failing  memory  and 
judgment,  increased  irritability,  and,  in  addition,  such 
physical  signs  as  fainting  spells,  transitory  speech  dis- 
turbances, syncopal  attacks,  and  headaches.  Occasionally 
the  onset  is  quite  sudden. 

Following  these  prodromal  symptoms,  there  may  first 


302  FORMS  OF  MENTAL  DISEASE 

develop  the  picture  of  the  depressed  type  with  delusions  of 
persecution,  self-accusation,  and  anxiety,  but  usually  from 
the  onset  there  is  a  condition  of  excitement  with  elation, 
and  grandiose  delusions,  during  which  transitory  states  of 
depression  with  weeping  may  occur.  In  case  there  have 
been  signs  of  despondency  and  illness,  these  then  disappear 
and  the  patients  gradually  —  occasionally  suddenly  —  de- 
velop a  marked  feeling  of  well-being;  they  are  bright, 
affable,  talkative,  and  energetic.  They  busy  themselves 
with  new  and  elaborate  schemes  for  getting  wealthy,  stake 
out  property,  and  draw  designs  for  wonderful  machines. 
They  are  busy  from  early  morning  to  late  at  night,  soliciting 
patronage,  ordering  large  quantities  of  material  for  building 
and  for  other  purposes.  The  numerous  expansive  delusions 
at  first  are  within  the  range  of  possibility  and  may  appear 
attractive  to  the  unsuspecting,  but  soon  pass  into  the  realm 
of  absurd  imagination,  reminding  one  very  much  of  the 
prattle  of  children.  These,  with  the  restlessness,  present 
the  characteristic  picture  of  megalomania.  The  patients 
claim  never  to  have  felt  better  in  their  lives,  can  lift  tons, 
can  whip  the  best  man  on  earth,  have  the  strength  of  a 
thousand  horses,  and  can  move  a  train. 

They  believe  their  English  the  best ;  they  speak  as  fluently 
several  other  languages;  their  voice  is  clear  and  distinct 
and  can  be  heard  for  many  blocks,  because  of  its  excellent 
qualities.  They  have  the  inspiration  to  write  a  book;  can 
compose  beautiful  poems;  can  deliver  an  oration  on  any 
subject.  They  associate  only  with  the  most  cultured  people; 
only  the  genuine  blue  blood  courses  through  their  veins; 
they  are  going  to  build  a  marble  mansion  at  Newport,  and 
have  a  floating  palace.  Business  is  flourishing;  they  are 
making  a  "  mint  of  money/'  have  several  gangs  of  men 
working  for  them,  and  still  there  is  more  work  than  they 


DEMEXTTA  PARALYTICA  303 

can  attend  to;  besides  their  regular  business,  chickens  are 
being  raised  by  a  special  method  at  an  enormous  profit; 
they  have  secured  rich  gold  claims  in  Nevada,  which  are 
doubling  in  wealth  daily. 

Formerly  they  were  brakemen,  but  now  run  the  fastest 
and  finest  train  in  the  world  from  New  York  to  Chicago 
without  a  single  stop,  allowing  none  but  millionnaires  to  ride; 
besides  a  profitable  law  business,  they  are  now  engaged  in 
writing  a  novel  which  will  startle  the  world,  and  for  which 
they  have  received  priceless  offers  from  publishers  in  this 
country  and  in  Europe.  A  ship  carpenter  developed  wonder- 
ful power  in  his  eyes,  so  that  he  could  detect  defective  wood 
in  a  vessel  by  simply  standing  in  the  hold  and  looking  out- 
ward, and  for  this  reason  he  was  appointed  detective  of  a 
marine  insurance  company,  and  had  travelled  all  over  the 
world  inspecting  vessels.  He  had  become  so  wealthy  that 
all  the  banks  in  the  state  were  in  his  possession. 

A  seamstress  had  devised  a  new  method  for  cutting 
dresses,  which  had  won  her  world-wide  fame,  having  been 
called  to  all  of  the  courts  of  Europe  because  of  her  wonderful 
success.  She  herself  could  cut  and  sew  a  hundred  dresses 
a  day,  and  had  under  her  five  hundred  girls,  all  of  whom 
used  gold  thread.  She  could  sew  on  a  thousand  buttons  a 
minute.  A  jockey  had  discovered  a  new  way  of  breeding 
and  training  runners,  and  now  from  his  Kentucky  ranch 
was  supplying  every  circuit  and  handicap  with  winners. 

The  utter  absurdities  which  increase  from  day  to  day  are 
proof  of  the  increasing  mental  weakness.  The  delusions 
abound  in  contradictions  and  become  more  incoherent,  the 
product  of  a  more  dreamy  ingenuity.  The  patient  now 
drives  the  largest  engine  in  the  world,  drawing  a  thousand 
palace  cars,  all  fined  with  gold  and  trimmed  with  pearls, 
which  encircles  the  globe  every  twenty-four  hours,  stopping 


304  FORMS  OF  MENTAL  DISEASE 

only  at  New  York,  San  Francisco,  Calcutta,  Paris,  and  Lon- 
don. He  now  has  formed  a  chicken  trust  to  extend  over  the 
whole  earth,  and  will  reconstruct  the  social  system  of  the 
world,  so  that  only  the  Chinese  will  be  employed  in  hatch- 
ing the  eggs.  Another  has  a  most  wonderful  herd  of  cattle, 
whose  horns  are  forty  feet  high,  whose  eyes  are  diamonds, 
whose  feet  are  gold,  and  each  cow  produces  five  hundred 
pails  of  milk  in  twenty-four  hours,  the  patient  himself  milk- 
ing a  thousand  a  day. 

The  patients  are  the  most  beautiful  beings  that  ever  lived. 
They  have  married  seven  hundred  millionnaires,  have  twenty 
thousand  children,  all  of  whom  have  gold  slippers  and  gold 
dresses;  they  themselves  wear  only  diamond  trimmings; 
they  can  fly  away  in  the  air  to  a  world  where  there  is  a 
castle  ten  thousand  miles  long  filled  with  lovely  people  who 
do  nothing  but  amuse  themselves.  They  are  not  human, 
but  divine;  can  create  a  universe,  visit  all  the  stars,  have 
sent  Christ  to  Mars;  whatever  they  touch  turns  to  gold. 
They  know  all  sciences,  are  the  greatest  physicians  in 
existence;  will  build  a  hospital  of  marble  twenty  stories 
high,  provided  with  a  bar  for  the  doctors,  where  the  choicest 
wines  and  the  best  Havana  cigars  will  be  supplied ;  and  there 
will  be  a  dissecting  room,  with  a  huge  ice  box,  where  ten 
thousand  bodies  can  be  kept  all  the  time. 

They  will  build  a  tunnel  through  the  earth  and  bring  all 
the  Chinamen  here  to  work.  One  patient  said  that  he  was 
going  to  build  towns;  that  he  had  been  to  Washington  to 
see  the  President,  that  he  wanted  six  thousand  billion  gun- 
boats, one  million  bomb-shell  boats,  one  million  marines,  and 
that  he  would  cross  the  ocean  and  blow  up  all  of  the  coun- 
tries and  bring  the  people  out  west  and  put  them  on  farms; 
that  he  would  blow  up  the  Queen's  buildings,  and  that  he 
would  give  each  one  of  the  marines  two  bags,  and  each 


DEMENTIA  PARALYTICA  305 

would  have  to  go  two  times  in  order  to  bring  away  the  silks 
and  diamonds. 

These  delusions  are  almost  entirely  self-centered.  They 
may  change  rapidly,  each  day  new  and  extravagant  ideas 
appearing,  which  are  filled  with  the  most  glaring  contra- 
dictions. In  women  the  tendency  to  expansiveness  is  less 
marked.  Transitory  hallucinations  of  sight  and  hearing  are 
occasionally  expressed,  but  they  never  take  a  prominent 
part  in  the  disease  picture. 

Consciousness  is  somewhat  clouded  during  the  develop- 
ment of  the  megalomania.  There  is  usually  disorientation 
for  time,  places,  and  persons,  —  the  patients  are  too  much 
absorbed  in  their  numerous  ideas  to  note  the  surroundings 
or  to  take  account  of  time.  Later  they  become  acquainted 
with  the  place  and  a  few  of  the  persons,  but  they  rarely 
know  the  month,  day,  or  the  year.  The  content  of  thought  is 
centered  entirely  about  self  and  the  many  varied  delusions. 
At  first  it  is  usually  coherent,  although  at  times,  in  connec- 
tion with  great  psychomotor  restlessness,  there  may  be  in- 
coherence, distractibility,  and  sometimes  flight  of  ideas. 
The  patients  are  usually  talkative,  and  may  produce  a  con- 
tinuous stream  of  delusions.  Incoherence  of  thought  is 
more  evident  in  their  letters. 

The  emotional  attitude  corresponds  closely  to  the  content 
of  the  delusions;  the  patients  are  cheerful,  happy,  hopeful, 
contented,  and  exalted.  Everything  in  the  environment  is 
pleasing;  they  are  in  luxurious  quarters,  have  the  best  of 
food,  plenty  of  servants,  fine  clothing,  fast  horses,  and  are 
associated  with  the  finest  men  in  the  world.  It  often  hap- 
pens that  for  a  short  time,  a  few  moments  or  hours,  rarely 
days,  they  lose  spirits  and  become  depressed,  complaining 
of  confinement,  and  expressing  hypochondriacal  delusions, 
or  weep  bitterly  because  of  harassing  persecutions.   Even 


306  FORMS  OF  MENTAL  DISEASE 

when  most  miserable  it  is  often  possible  by  suggestions  to 
reestablish  the  feeling  of  well-being,  showing  the  great  in- 
stability of  the  emotional  condition.  Increased  irritability 
is  always  present,  manifesting  itself  upon  the  slightest 
provocation.  Disagreements  or  doubts  relative  to  their 
superiority  or  immense  wealth  may  arouse  anger  or  even  an 
aggressive  attack.  Later  in  the  course  of  the  disease  the 
patients  are  usually  in  a  uniform  state  of  quiet  cheerfulness 
in  spite  of  their  bedridden  condition  with  filthiness,  paralysis, 
and  even  contractures.  The  paretic  on  his  deathbed,  when 
asked  how  he  feels,  often  drawls  out  with  some  animation, 
"  Fine,  fine." 

In  the  psychomotor  field  excitement  predominates  from 
the  onset  and  may  reach  an  extreme  degree.  At  first  the 
patients  are  restless,  bustling  about  on  new  and  important 
business,  remaining  up  until  late  at  night,  devising  plans, 
writing  many  letters,  and  travelling  about  from  place  to 
place.  They  are  very  talkative  and  make  confidants  of 
every  one  they  meet.  For  short  periods  in  the  course  of  the 
disease  they  may  develop  extreme  restlessness,  with  insomnia, 
complete  clouding  of  consciousness,  recklessness,  aggressive- 
ness, and  impulsiveness.  They  shout  from  fear,  mutilate 
their  own  bodies,  and  rush  about  blindly  diving  into  any 
obstacle.  It  is  impossible  to  attract  their  attention  or  to 
get  coherent  answers.  They  fight  off  imaginary  enemies  and 
shout  threats  and  curses.  These  conditions  of  excitement 
rarely  last  longer  than  a  few  hours  or  days,  and  disappear 
gradually,  usually  leaving  the  patient  in  a  state  of  more 
profound  deterioration. 

In  actions  the  patients  soon  become  foolish  and  show  a 
lack  of  judgment  and  moral  obtuseness.  They  develop  bad 
habits,  smoke  or  swear,  enjoy  telling  obscene  stories,  seek 
the  company  of  lascivious  women,  and  become  disorderly  in 


DEMENTIA  PARALYTICA  307 

dress  and  careless  in  appearance.  They  may  assault  or 
commit  thefts,  but  every  action  shows  an  absence  of  plan, 
recklessness,  and  utter  disregard  for  others.  When  con- 
fronted with  their  observed  behavior,  it  is  all  denied  with 
perfect  serenity. 

As  the  disease  advances,  the  activity  is  limited  to  the 
production  of  unintelligible  letters  and  plans,  scribbling 
on  paper,  and  collecting  useless  rubbish.  The  patients  are 
happy  and  contented  throughout  it  all,  invariably  asserting 
with  brightening  countenance  that  they  are  feeling  fine. 
They  may  be  heard  mumbling  to  themselves,  "  millions," 
"  fine  horses,"  "beautiful  women,"  "  grand  mansions,"  — 
mere  relics  of  former  ideas  which  now  represent  the  last 
traces  of  their  intellectual  life. 

The  expansive  form  comprises  from  fifteen  to  sixteen  per 
cent,  of  the  paretics.  The  duration  is  more  prolonged,  less 
than  one-third  of  the  cases  dying  within  two  years.  Some 
cases  even  live  fourteen  years.  Remissions  occur  in  one- 
third  of  the  cases,  which  in  part  accounts  for  the  prolonged 
course.  It  sometimes  happens  that  the  expansive  form 
passes  over  into  the  depressive,  and  vice  versa,  and  this  may 
take  place  several  times,  simulating  the  picture  of  manic- 
depressive  insanity. 

Agitated  Form 

The  agitated  form  is  characterized  by  a  relatively  sudden 
onset  with  a  condition  of  great  psychomotor  excitement  and 
delirium,  and  the  presence  of  the  most  extremely  expansive  delu- 
sions, great  clouding  of  consciousness,  and  a  short  course.  The 
usual  prodromal  symptoms  are  lacking  and  there  rapidly 
develops  extreme  megalomania.  A  change  of  disposition  is 
often  noticed  for  a  time  previous  to  the  sudden  outbreak. 
The  patients  rapidly  become  very  energetic,  and  express  a 
pronounced  feeling  of  well-being.    They  are  born  again, 


308  FORMS  OF  MENTAL  DISEASE 

possess  the  ambition  and  the  strength  of  ten  thousand  men ; 
could  carry  an  ocean  vessel  or  fly  to  the  moon  in  a  second. 
They  have  acquired  all  knowledge,  can  educate  a  thousand 
men  an  hour,  teaching  them  to  speak  every  known  language. 
They  themselves  are  Gods,  Gods  over  God,  have  created  God 
and  the  universe;  have  been  everywhere  from  the  heights 
of  heaven  to  the  depths  of  hell.  They  are  now  establishing 
a  new  method  of  reckoning  time;  by  their  decree  the  days 
are  to  be  one  thousand  hours  long,  the  weeks  are  to 
contain  one  thousand  days,  and  the  years  ten  thousand 
months.  They  know  how  to  create  animals,  and  by  a  new 
formula  man  shall  be  increased  a  hundred-fold  in  size  and 
shall  have  a  third  eye.  The  world  moves  and  stands  at 
their  command.  They  are  interested  in  all  wars  and  have 
marshalled  huge  armies.  Their  wealth  is  fabulous,  more 
than  any  one  man  ever  possessed  before.  All  quantities  are 
reckoned  in  the  ten  thousand  billions;  they  own  ten  thou- 
sand billion  houses;  ten  thousand  billion  cows;  ten  thou- 
sand billion  acres  of  land,  etc.  Their  houses  are  built  of 
Italian  marble,  with  gilded  domes  set  with  diamonds,  the 
floors  are  of  onyx,  the  furniture,  pure  gold,  and  the  hang- 
ings, the  finest  fabric,  trimmed  with  pearls  and  sapphires. 
Their  ideas  become  more  and  more  expansive,  and  finally 
seem  even  to  surpass  the  bounds  of  imagination. 

In  the  midst  of  these  megalomanic  delusions,  one  occasion- 
ally encounters  the  most  extremely  pessimistic  ideas  which 
are  sometimes  hypochondriacal.  The  patients  claim  that 
they  are  suffering  untold  misery  from  sharp  pains  in  the 
back;  some  one  entered  the  room  at  night  and  disem- 
bowelled them,  so  that  the  following  morning  they  could 
not  go  to  stool;  miles  of  fine  electric  wires  have  been  placed 
in  the  flesh,  about  the  limbs  and  completely  filling  the  skull, 
through  which  electrical  currents  are  nightly  applied,  causing 


DEMENTIA  PARALYTICA  309 

the  flesh  to  burn.  There  may  be  some  insight  into  the  fail- 
ing memory  and  the  defective  nutrition,  which  leads  them 
momentarily  to  fear  that  they  are  suffering  from  cancer  of 
the  most  malignant  type,  but  at  the  same  time  one  is 
assured  that  they  are  undergoing  a  process  of  purification 
which  will  leave  them  healthier  and  mightier.  Sometimes 
they  are  perplexed  at  their  own  stupidity  for  allowing  them- 
selves to  be  confined  in  a  hospital  instead  of  going  to  Europe 
to  consummate  a  deal  by  which  millions  would  have  been 
made.  Hallucinations  of  sight  and  hearing  may  be  present, 
but  are  not  prominent,  and  fail  to  influence  greatly  the 
clinical  picture. 

The  psychomotor  condition  is  one  of  great  restlessness, 
showing  occasional  impulsive  movements.  The  patients 
are  talkative,  sing,  laugh,  shout,  and  prattle  away  like 
children  over  their  innumerable  plans  and  many  pleas- 
ures. They  are  constantly  in  motion,  going  from  one  thing 
to  another,  working  in  a  planless  way  on  various  schemes, 
scribbling  unintelligible  letters  to  millionnaire  friends,  issuing 
commands  to  military  staffs,  and  sending  cablegrams  to  the 
different  crowned  heads.  They  have  no  care  for  themselves, 
neglect  personal  appearance,  forget  about  eating,  smear 
their  dresses  or  the  walls  with  the  food  placed  before  them, 
masturbate,  and  expose  themselves  indecently. 

Thought  is  usually  incoherent,  and  there  is  often  observed 
a  flight  of  ideas.  Emotionally,  there  is  a  marked  irritability, 
and  interference  quickly  leads  to  outbursts  of  passion,  with 
cursing,  threats,  and  aggressiveness;  bat  elation  predomi- 
nates. Physically,  the  condition  of  nutrition  suffers  pro- 
foundly, and  there  is  a  great  loss  of  weight,  because  of  the 
small  amount  of  food  ingested  and  great  restlessness.  The 
temperature  may  be  subnormal. 

A  few  cases  of  the  agitated  form  may  be  characterized  as 


310  FORMS  OF  MENTAL  DISEASE 

galloping  paresis.  These  cases  present  an  extreme  grade  of 
excitement  and  profound  clouding  of  consciousness,  leading 
within  a  few  weeks  or  months  to  fatal  collapse.  It  sometimes 
represents  the  end  stage  of  the  agitated  form  and  occa- 
sionally also  of  the  depressed  form.  The  patients  are  com- 
pletely confused,  unable  to  comprehend  the  surroundings 
or  to  respond  to  questions.  They  are  noisy,  shouting  and 
singing,  producing  an  unintelligible  babble,  with  many 
repetitions  of  syllables  or  purely  inarticulate  sounds.  The 
restlessness  is  extreme,  the  patients  being  in  constant  motion, 
pounding  the  bed  or  wall,  forcing  the  legs  up  and  down, 
running  about  the  room,  slapping  their  hands,  waltzing  to 
and  fro,  and  bruising  themselves  extensively  by  their  reck- 
less movements.  Insomnia  is  extreme  and  food  is  refused, 
or  if  taken,  cannot  be  retained,  and  the  patients  are  wholly 
unable  to  care  for  their  personal  needs.  The  weight  falls 
rapidly,  the  temperature  becomes  slightly  elevated,  and  the 
heart's  action  feeble  and  irregular.  Epileptiform  and 
apoplectiform  attacks  are  frequent.  Within  a  few  days  or 
weeks  the  restlessness  subsides  into  a  condition  of  stupor, 
in  which  the  movements  are  uncertain  and  tremulous.  The 
temperature  becomes  elevated  as  the  result  of  infection  from 
the  various  wounds  or  acute  decubitus,  the  mouth  is  filled 
with  sordes;  profuse  perspiration  and  diarrhoea  appear, 
which  with  heart  failure  lead  to  death. 

The  agitated  form  represents  about  eleven  per  cent,  of  the 
paretics.  Remissions  occur  in  one-fourth  of  the  cases. 
Paralytic  attacks  are  frequent.  The  duration  in  more 
than  two-thirds  of  the  cases  is  less  than  two  years. 

Depressed  Form 

This  form  is  characterized  by  despondency  and  depressive  de- 
lusions which  prevail  throughout  the  whole  course  of  the  disease. 


DEMENTIA  PARALYTICA  311 

The  onset  in  this  form  is  insidious.  The  patients  notice 
their  failing  memory,  decreasing  power  of  application, 
greater  weariness  upon  exertion,  and  change  of  disposition. 
The  persistent  headaches,  the  numerous  pains,  and  failing 
memory  lead  them  to  consult  one  physician  after  another. 
They  worry  about  themselves  and  soon  become  hypochon- 
driacal. They  claim  that  they  are  suffering  from  a  complica- 
tion of  diseases  and  that  they  can  never  recover.  During 
this  stage  they  are  not  infrequently  regarded  as  neuras- 
theniacs,  hypochondriacs,  or  hysterical  patients. 

But  their  hypochondriacal  complaints  sooner  or  later  be- 
come entirely  senseless.  They  then  complain  that  the  scalp 
is  rotting  away,  the  skull  is  filling  in  with  bone,  causing  the 
brain  to  shrink,  the  mouth  is  filled  with  sores,  the  sense  of 
taste  is  lost,  the  throat  is  clogged  up,  so  that  the  food  passes 
up  into  the  brain,  the  stomach  is  melted  away,  and  the 
intestines  are  so  paralyzed  that  excrement  has  been  accu- 
mulating within  them  for  many  months,  the  kidneys  have 
been  moved,  so  that  water  passes  directly  through  their 
bodies.  They  claim  that  they  are  dead,  the  blood  has 
ceased  to  circulate,  and  they  have  turned  to  stone.  The 
testicles  have  dried  up  and  their  manhood  has  disappeared ; 
a  false  passage  has  formed  so  that  the  "  vital  fluid  "  passes 
out  of  the  rectum.  In  connection  with  these  ideas  they  are 
constantly  fingering  different  parts  of  the  body,  especially 
the  face  and  sexual  organs.  They  may  sit  for  hours  with 
hands  on  their  throat  for  fear  feces  will  pass  into  the  mouth, 
or  may  lie  abed  as  if  dead,  claiming  that  they  would  fall 
apart  if  moved. 

Delusions  of  self-accusation  are  usually  associated  with 
these  hypochondriacal  ideas  and  occasionally  predominate 
in  the  clinical  picture.  The  patients  believe  themselves 
great  sinners,  that  they  have  committed  the  unpardonable 


312  FORMS  OF  MENTAL  DISEASE 

sin,  must  die  on  the  cross,  have  stolen  property,  and  injured 
their  children.  They  have  caused  the  death  of  a  friend  by 
negligence,  and  every  one  knows  that  they  are  murderers. 
They  persist  that  they  have  always  been  impure  and  have 
led  many  astray.  A  patient  moaned  for  months  because  he 
had  not  provided  his  family  with  sufficient  food  and  was 
being  held  up  to  the  whole  world  as  an  example  and  must 
suffer  the  penalty  of  death.  Very  often  fear  develops  in 
connection  with  these  ideas  of  self-accusation,  when  the 
patients  are  in  terror  because  they  are  being  constantly 
watched,  expecting  at  any  moment  to  be  imprisoned  or 
carried  away  to  the  scaffold;  or  they  dread  personal  injury 
and  abuse. 

Delusions  of  persecution  are  usually  accompanied  by  hal- 
lucinations of  hearing,  when  they  suspect  plots  against  their 
lives  and  complain  that  their  families  are  being  outraged. 
They  are  being  regarded  as  desperadoes  on  whose  head  there 
is  a  high  price.  The  troops  have  been  summoned  to  escort 
them  into  exile.  They  hear  themselves  slandered  by  a 
crowd  of  men  outside,  or  overhear  intrigues  against  them. 
Others  threaten  them.  Hallucinations  of  the  other  senses 
are  infrequent. 

The  consciousness  soon  becomes  much  clouded.  There  is 
considerable  disorientation;  friends  are  mistaken,  and  time 
is  confused.  Occurrences  in  the  surroundings  have  reference 
only  to  themselves.  The  bathing  of  others  suggests  to  their 
minds  that  they  have  polluted  their  fellow-patients,  and  the 
preparation  for  the  morning  walk  signifies  that  the  whole 
company  are  getting  ready  to  attend  their  public  prosecu- 
tion. At  the  table  others  are  deprived  of  food  on  their 
account.  In  this  condition  they  develop  great  anxiety  with 
restlessness;  pace  back  and  forth  in  their  rooms,  moaning 
and   groaning,   sometimes  uttering   single   expressions,   as 


DEMENTIA  PARALYTICA  313 

"  death,"  "  destruction,"  pick  at  their  finger-nails,  pull  out 
their  hair,  and  are  unable  to  eat.  Every  unusual  sound 
frightens  them  and  causes  them  to  shudder  and  shrink  back 
farther  into  their  rooms.  Finally  they  cannot  be  persuaded 
to  leave  the  bed,  but  lie  huddled  up  at  one  side,  with  the 
head  buried  in  the  clothing.  In  this  condition  they  may 
attempt  suicide  or  mutilate  their  own  bodies;  one  patient 
tore  through  the  anal  sphincter  into  the  vagina  with  her 
hand. 

Extreme  anxiety  with  restlessness  does  not  exist  very 
long  at  a  time,  usually  only  for  a  few  hours  or  at  most  a 
few  weeks.  It  may  appear  and  disappear  suddenly.  In 
the  interval  the  patients  are  not  as  agitated  but  yet  are 
despondent  and  seclusive.  The  depressive  delusions  are  re- 
tained but  they  show  far  less  emotion.  The  mental  depres- 
sion is  not  always  uniform,  as  one  occasionally  notices 
emotional  indifference,  and  even  transitory  periods  with  a 
feeling  of  well-being  and  of  elation.  When  deterioration 
is  well  advanced,  expansive  delusions  occasionally  appear. 

More  or  less  prolonged  stuporous  states  appear  at  times 
during  the  course  of  the  disease,  when  the  patients  become 
mute,  lying  abed  in  one  position  oblivious  to  the  surround- 
ings, refusing  nourishment,  and  allowing  the  feces  and  urine 
to  pass  unheeded.  Requests  are  carried  out  slowly  or  wholly 
ignored.  The  patients  appear  indifferent,  but  at  times  they 
display  some  emotion,  or  they  may  show  some  anxiety. 
Hallucinations  and  illusions  may  be  more  or  less  prominent 
or  entirely  wanting.  Consciousness  is  usually  clouded. 
These  states  may  last  several  months. 

The  depressive  form  of  dementia  paralytica  comprises 
one-fourth  of  the  cases,  and  appears  rather  late  in  life, 
mostly  after  forty  years  of  age.  Remissions  occur  in  less 
than  twelve  per  cent,  of  the  cases,  while  paralytic  attacks 


314  FORMS  OF  MENTAL  DISEASE 

occur  in  twenty-five  per  cent.  This  type  is  one  of  the 
severer  forms,  as  over  seventy  per  cent,  die  within  two 
years. 

Course  of  dementia  paralytica. — Dementia  paralytica  may 
be  divided  into  three  stages :  the  stage  of  onset,  the  stage  of 
acute  symptoms,  and  the  terminal  stage  of  dementia.  The  lines 
of  division  are  very  indefinite,  as  the  first  stage  may  very  quickly 
pass  into  the  acute  stage,  when  the  symptoms  remain  in  abey- 
ance for  a  few  years ;  or  the  case  may  be  one  of  apathetic  dete- 
rioration from  the  onset,  devoid  of  any  prominent  symptoms 
indicative  of  definite  stages.  The  terminal  stage  is  apt  to 
be  prolonged.  In  it  the  patients  are  dull,  stupid,  apathetic, 
entirely  indifferent  to  their  surroundings,  unable  to  care  for 
themselves,  or  occasionally  expressing  incoherent  fragments 
of  former  delusions.  They  sit  unoccupied  save  for  the  taking 
of  nourishment,  to  which  they  often  have  to  be  helped.  The 
physical  symptoms  in  this  stage  advance  to  general  paresis 
of  all  of  the  muscles,  necessitating  confinement  in  bed. 
Sensation  is  greatly  impaired,  muscular  atrophy  and  weak- 
ness become  marked,  and  finally  contractures  appear.  In 
the  end  patients  become  nothing  more  than  vegetating 
organisms.  The  course  of  the  physical  symptoms  by  no 
means  correspond  to  those  of  the  mental  symptoms.  On 
the  one  hand,  there  are  cases  in  which  speech  disturbances 
and  incoordination  may  antedate  for  a  long  time  the  ap- 
pearance of  faulty  memory  or  judgment,  and  on  the  other 
hand,  the  mental  symptoms  may  appear  first. 

The  two  important  factors  in  the  course  of  the  disease  are 
paralytic  attacks  and  remissions.  The  attacks  may  appear 
at  any  time  during  the  course,  producing  an  unexpected 
progress  in  the  deterioration  or  even  a  fatal  termination. 
They  may  usher  in  the  disease,  being  followed  by  a  condition 
of  advanced  deterioration,  but  more  frequently  occur  during 


DEMENTIA  PARALYTICA  315 

the  terminal  stage.  These  attacks  accompany  chiefly  the 
demented  and  the  expansive  forms. 

Remissions  are  most  often  encountered  in  the  agitated  and 
expansive  forms  and  very  rarely  in  the  demented  forms.  The 
improvement,  which  is  usually  rapid,  appears  only  during  the 
earlier  stages  of  the  disease.  Both  the  physical  and  mental 
symptoms  show  marked  improvement;  the  consciousness 
becomes  clear,  the  content  of  thought  coherent,  and  the 
delusions  and  hallucinations  disappear.  The  patients  often 
look  back  upon  their  psychosis  as  a  sort  of  dream,  without 
clear  insight.  In  the  course  of  a  month  or  two  they  may 
have  improved  so  much  that,  as  far  as  the  limited  associations 
of  the  institution  permit,  they  appear  perfectly  well.  When 
at  liberty,  however,  it  is  apparent  to  their  friends  that  they 
have  lost  their  former  mental  energy;  they  tire  easily,  and 
are  changed  in  disposition.  Yet  they  are  usually  eager  for 
employment  and  disregard  the  advice  of  the  physicians  to 
exercise  care.  Some  of  the  patients  are  able  to  engage 
successfully  in  their  former  occupation  and  support  their 
families.  In  other  cases  the  remission  is  only  partial;  the 
patients  become  clear  and  coherent,  while  the  expansive 
and  depressive  delusions  disappear;  but  there  still  remains 
a  tendency  to  excessive  activity,  with  a  desire  to  enter  into 
uncertain  business  ventures,  to  be  lavish  with  money,  care- 
less in  personal  appearance,  and  irritable  and  fretful  in  dis- 
position. The  duration  of  the  remission  seldom  lasts  over 
three  or  four  months,  but  in  some  cases  it  extends  over  three 
or  more  years. 

Diagnosis.  —  During  the  early  stages  of  paresis,  there  may 
be  considerable  difficulty  in  distinguishing  acquired  neuras- 
thenia (see  p.  153). 

The  depressive  form  of  paresis  is  distinguished  from  melan- 
cholia of  involution  by  the  evidences  of  mental  deterioration : 


316  FORMS  OF  MENTAL  DISEASE 

weakness  of  judgment,  moral  instability,  failure  of  memory, 
defective  time  orientation,  silliness  and  incoherence  of  the 
delusions,  and  presence  of  physical  signs.  The  melancholiac 
shows  a  greater  prominence  of  self-accusations  and  good 
orientation,  except  in  cases  with  many  hallucinations  and 
delusions.  The  intense  apprehensiveness  of  the  paretic  is 
less  persistent  than  that  encountered  in  melancholia,  and  is 
occasionally  relieved  by  short  periods  of  moderate  but 
distinct  feeling  of  well-being.  The  melancholiacs  have 
their  good  days,  but  they  never  show  elation. 

The  depressive  phases  of  manic-depressive  insanity  are  dis- 
tinguished by  the  absence  of  any  signs  of  mental  deteriora- 
tion and  by  the  presence  of  retardation  among  the  motor 
phenomena.  In  the  stuporous  states  the  manic-depressive 
patient  takes  some  notice  of  and  partially  apprehends  his 
surroundings,  although  he  takes  no  part  in  them;  he  shows 
some  anxiety  and  discomfort  when  threatened  with  a  needle 
and  seldom  moves  voluntarily  and  then  slowly,  while  the 
paretic  is  partially  disoriented,  does  not  react  when  threat- 
ened with  a  needle,  and  occasionally  moves  freely  and  even 
restlessly,  and  usually  presents  characteristic  physical  signs. 

The  manic  phases  of  manic-depressive  insanity  are  dif- 
ferentiated from  the  expansive  and  agitated  forms  of  paresis 
by  the  absence  of  mental  deterioration.  The  paretic  is  un- 
able to  recall  correctly  recent  events,  and  especially  the  date 
of  their  occurrence.  His  delusions  are  more  extreme, 
fantastic,  and  contradictory;  his  emotional  attitude  is 
variable,  and  dependent  upon  the  surroundings  and  sug- 
gestions, and  he  is  more  pliable.  The  manic,  on  the  other 
hand,  is  more  alert  and  quick  in  apprehending  when  his 
attention  can  be  attracted;  he  shows  an  accurate  memory; 
his  delusions  are  less  often  contradictory,  are  expressed  with 
less  assurance  and  more  facetiousness;   and  he  is  seldom 


DEMENTIA  PARALYTICA  317 

contented  and  is  less  pliable.  In  conditions  of  extreme  excite- 
ment, the  orientation  and  the  coherence  of  thought  is  more 
disturbed  in  paresis. 

It  often  happens  that  periods  of  excitement  at  the  onset 
of  the  disease  are  mistaken  for  delirium  tremens,  especially 
where  early  paretic  symptoms  have  escaped  notice  in  an 
alcoholic  (see  p.  183). 

Dementia  prcecox  is  usually  differentiated  by  the  absence 
of  the  characteristic  physical  signs,  good  orientation,  and 
the  presence  of  catatonic  features  (see  p.  270).  The  so- 
called  catatonic  symptoms,  if  they  occur  in  paresis,  are  ac- 
companied by  a  greater  disturbance  of  memory  and  greater 
insensibility  and  cloudiness  than  what  one  encounters  in 
dementia  precox.  In  case  these  distinguishing  features 
cannot  be  determined,  on  account  of  negativistic  signs,  then 
one  has  to  depend  upon  the  presence  or  absence  of  physical 
signs.  The  presence  of  simple  difference  of  pupils,  increased 
reflexes,  moderate  tremor,  and,  indeed,  even  attacks  of  dizzi- 
ness and  of  an  epileptiform  nature,  are  not  conclusive  for 
paresis.  If  a  patient  with  such  symptoms  is  uncertain  and 
helpless  in  simple  figuring  tests,  is  unable  to  orient  himself 
as  regards  time  and  to  readily  recall  early  experiences,  and  is 
easily  influenced  in  action  and  feeling,  provided  it  is  not  the 
mechanical  response  to  stimuli,  then  the  condition  is  more 
indicative  of  paresis.  The  states  of  dementia  in  paresis  lack 
the  tendency  to  adornment,  the  mannerisms,  the  occasional 
exacerbations,  and  the  persistent  stupor,  negativism,  and 
refusal  of  food.  In  the  paretic  excitement,  there  may  occur 
impulsive  and  stereotyped  movements;  but  they  are  not 
accompanied  by  the  irrelevant  and  incoherent  speech  of  the 
catatonic,  and  furthermore,  the  excited  paretic  is  not 
oriented  to  the  extent  that  the  catatonic  usually  is.  In  the 
paranoid  forms  there  is  neither  the  paretic  inability  to  com- 


318  FORMS  OF  MENTAL  DISEASE 

prehend  the  surroundings  nor  the  permanent  feeling  of  well- 
being,  hallucinations  are  much  more  frequent  and  expansive 
delusions  develop  more  slowly,  while  the  paretic  does  not  show 
the  delusions  of  influence  so  common  in  paranoid  dementia. 
The  late  cases  of  dementia  praecox,  in  which  despondency  may 
predominate,  are  distinguished  by  the  susceptibility  to  ex- 
ternal influences,  such  as  commands,  and  by  the  impulsive 
restlessness  or  stupor  with  resistiveness.  Ultimately  the 
diagnosis  may  rest  upon  the  examination  of  the  cerebro- 
spinal fluid. 

The  differentiation  of  paresis  is  apt  to  be  most  difficult 
in  those  diseases  in  which  there  are  extensive  cortical  lesions, 
particularly  cerebral  syphilis  (see  p.  331),  arteriosclerotic 
insanity  (see  p.  338),  and  senile  dementia.  Senile  dementia 
may  be  recognized  by  the  age  at  onset,  the  more  prolonged 
course,  comparative  poverty  of  delusions,  and  absence  of 
characteristic  motor  symptoms. 

Cases  of  cerebral  tumor  occasionally  present  mental  symp- 
toms similar  to  those  in  the  demented  form  of  dementia 
paralytica.  The  chief  point  of  differentiation,  in  case  no 
focal  symptoms  exist,  is  the  presence  of  the  cupped  optic 
disk. 

Prognosis.  —  The  prognosis  of  the  disease  is  decidedly  un- 
favorable. Death  occurs  in  the  vast  majority  of  cases  within 
two  years;  the  length  of  life,  however,  varies  in  the  differ- 
ent forms.  A  few  cases  survive  five  or  six  years.  One  case 
of  eighteen  years'  duration  has  been  reported.  There  are, 
however,  some  cases  of  so-called  arrested  paresis.  Undoubtedly 
not  a  few  of  these  cases  were  never  paresis  at  all,  but  rather 
belonged  to  the  group  of  organic  psychoses  characterized  by 
extensive  degenerative  changes  in  the  cortex,  especially 
syphilitic,  which  during  life  are  differentiated  only  with 
great  difficulty.     Again,  there  is  a  possibility  that  some  of 


DEMENTIA  PARALYTICA  319 

these  cases  represent  a  group  of  cases  still  undifferentiated, 
which  at  the  onset  present  the  characteristic  mental  and 
physical  symptoms  of  paresis,  but  later  subside  into  a 
condition  of  dementia  with  possibly  a  few  delusions  and  the 
residuals  of  the  former  physical  signs.  It  cannot  be  positively 
stated  that  some  of  these  are  not  paretic  cases  which  fail  to 
run  the  usual  fatal  course.  It  is  still  a  mooted  question 
whether  patients  may  not  even  recover  from  paresis.  In  the 
first  place,  Tuczek  reports  a  genuine  case  of  paresis,  con- 
firmed by  autopsy,  with  a  remission  of  twenty  years.  Again, 
Alzheimer  has  found  in  paretics,  dying  during  a  complete 
remission,  the  characteristic  paretic  lesions.  When  one 
considers  that  these  remissions  often  cannot  be  distinguished 
from  genuine  recoveries,  except  for  the  later  recurrence  of 
the  disease,  it  at  once  becomes  apparent  that  a  complete 
subsidence  of  all  mental  symptoms  may  occur,  which,  extend- 
ing through  a  series  of  years,  encourages  the  belief  that 
recoveries  are  possible.  The  immediate  causes  of  death 
are  paralytic  attacks,  pneumonia,  and  intercurrent  diseases, 
sometimes  septicaemia  following  infection  from  wounds, 
sometimes  suffocation  caused  by  food  entering  the  air 
passages;  but  the  usual  manner  of  death  is  from  marasmus 
and  heart  failure.  The  patients  become  emaciated,  the 
muscles  atrophy,  the  heart  weakens,  the  pulse  becomes  im- 
perceptible, and  life  gradually  flickers  out. 

Treatment.  —  The  treatment  of  the  disease  is  mostly  symp- 
tomatic. In  cases  where  there  is  a  history  of  probable 
syphilitic  infection  the  intensified  mercurial  treatment  is 
justified  by  the  small  number  of  reported  cures.1  It  consists 
in  the  intramuscular  injection  of  mercuric  salicylate  in 
albolene,  beginning  with  \  grain  twice  weekly  and  increasing 

1  Collins,  Med.  Record,  Vol.  9,  p.  125.  Dana,  Jour.  Amer.  Med.  Ass'n, 
May  6,  1905. 


320  FORMS  OF  MENTAL  DISEASE 

to  1^  grains,  administered  for  six  weeks,  and  then  an  interval 
of  six  months  during  which  general  tonics  are  pushed. 
Following  this,  another  period  of  similar  mercurial  treat- 
ment. Some  prefer  the  injection  of  bichloride  of  mercury, 
J  to  J  grain  daily,  given  for  six  to  eight  weeks,  repeated  after 
an  interval  of  six  months.  All  other  specific  methods  of 
treatment  have  fallen  into  disuse. 

It  is  of  utmost  importance  that  the  patient  be  submitted 
to  forced  rest,  with  removal  from  business  and  uncom- 
fortable surroundings,  and  the  establishment  of  a  suitable 
daily  routine  in  the  physical  and  mental  life.  Quiet  and 
tractable  patients  in  good  circumstances  may  be  treated  at 
home,  but  others  usually  require  sanitarium  or  hospital 
treatment.  Suitable  rest  and  relaxation  cannot  be  procured 
at  the  fashionable  health  resorts  with  the  numerous  "  cures  " 
and  attractions. 

Next  to  rest,  there  should  be  outlined  a  simple  nutritious 
diet,  including  abstinence  as  regards  alcohol,  coffee,  tea,  and 
tobacco.  A  carefully  planned  daily  routine,  including  ex- 
ercise in  the  open  air,  and  carefully  executed  hydrotherapy 
with  gentle  massage,  is  of  importance. 

The  conditions  of  paretic  excitement  are  best  relieved  by 
the  bed  treatment  and  the  use  of  the  prolonged  warm  baths 
(see  p.  140).1    At  the  first  application  of  the  bath,  it  may  be 

1  Where  the  warm  bath  is  inaccessible,  the  cold  packs  may  be  substi- 
tuted, which  in  the  hands  of  several  American  physicians  seem  to  give 
excellent  results.  The  packs  to  be  effective  must  be  properly  applied. 
The  partial  pack  usually  suffices  to  bring  about  the  desired  result,  apply- 
ing it  to  the  lower  extremities,  or  to  the  arms.  In  the  whole  pack  a  large 
and  heavy  woollen  blanket  is  spread  upon  the  mattress,  and  over  it  is  laid 
a  coarse  linen  sheet,  well  wrung  out  in  water  of  a  temperature  from  sixty 
to  seventy  degrees,  so  placed  that  the  patient  can  lie  at  the  junction  of 
the  middle,  and  right  third  of  the  sheet.  When  the  patient  is  in  position, 
with  the  arms  elevated,  and  provided  with  a  wet  turban,  the  right  portion 
of  the  sheet  is  drawn  across  the  body  and  tucked.    The  arms  are  lowered 


DEMENTIA  PARALYTICA  321 

necessary  to  give  preliminary  doses  of  hyoscine.  If  the 
excitement  is  extreme,  forced  feeding  or  hypodermoclysis 
with  normal  saline  solution  (see  p.  139)  given  twice  daily 
should  be  employed.  The  conditions  of  extreme  anxious 
restlessness  and  agitation  should  also  be  treated  with  the 
prolonged  warm  bath  and  if  necessary  the  use  of  the  hypo- 
dermoclysis, but  not  infrequently  these  patients  fail  to  yield 
to  any  form  of  treatment,  when  all  that  remains  to  be  done 
is  to  watch  the  patient  carefully  to  prevent  injuries  and  to 
maintain  nutrition. 

In  the  last  stages  of  the  disease,  extreme  cleanliness  is 
most  essential  in  order  to  prevent  bedsores.  The  bed- 
clothing  must  be  kept  dry,  clean,  smooth,  and  free  from 
crumbs,  and  the  body  frequently  cleansed  with  cold  water. 
Alcohol  or  hardening  applications  are  better  withheld,  and 
instead  the  skin  should  be  carefully  rubbed  with  cocoa 
butter.  Frequent  changes  of  the  position  of  the  body  every 
hour,  day  and  night,  aid  greatly  in  preventing  the  occurrence 
of  acute  decubitus  and  hypostatic  pneumonia.  Acute 
decubitus,  once  formed,  is  very  obstinate  and  should  be 
treated  surgically  like  an  ulcer.  Where  there  is  a  marked 
tendency  to  the  formation  of  acute  decubitus  and  also  where 
it  does  not  heal  readily,  the  best  method  is  to  keep  the 

to  the  side  and  covered  with  the  left  portion  of  the  sheet,  which  is  drawn 
across  the  body  and  securely  tucked,  especially  about  the  neck  and  feet. 
The  patient  is  then  covered  with  several  woollen  blankets.  The  duration 
of  the  pack  should  be  from  one-half  to  one  hour,  and  may  be  followed  by 
brisk  rubbing  with  alcohol.  The  duration  of  the  partial  pack  may  be 
more  extended  than  that  of  the  whole  pack.  When  the  patient  falls 
asleep  in  it,  it  is  not  necessary  that  it  be  removed  until  he  awakes. 
There  is  no  harm  in  an  immediate  renewal  of  the  partial  pack.  It  should 
be  remembered  in  the  application  of  these  partial  packs,  as  well  as  in  the 
whole  packs,  that  all  air  must  be  excluded  from  in  under  the  cover  of 
woollen  blankets,  for  which  purpose  many  use  a  final  covering  of  rubber 
cloth  or  oil  silk. 


322  FORMS  OF  MENTAL  DISEASE 

patient  continually  in  the  prolonged  warm  bath.  The 
nourishment  during  this  stage  must  be  liquid,  in  order  to 
prevent  choking.  Daily  percussion  of  the  lower  abdomen 
to  detect  distention  of  the  bladder  and  observation  of  the 
condition  of  the  bowels  is  also  necessary.  In  case  there  is 
paralysis  of  the  bladder,  the  patient  should  be  regularly 
catheterized,  followed  by  a  washing  of  the  bladder  with  a 
saturated  solution  of  boracic  acid.  Finally,  the  mouth 
should  be  kept  thoroughly  clean.  The  paralytic  attacks 
may  yield  to  ice  packs  on  the  head  or  to  amylene  hydrate 
(thirty  to  sixty  minims)  or  chloral  hydrate,  the  former  of 
which  may  be  given  by  subcutaneous  injections  in  a  five  to 
ten  per  cent,  solution.  If  immediate  action  is  demanded, 
chloroform  may  be  employed. 


VII.    ORGANIC  DEMENTIAS1 

The  term  is  here  used  in  a  limited  sense,  applying  only 
to  those  psychoses  that  are  associated  with  organic  dis- 
ease of  the  central  nervous  system,  and  includes  cerebral 
gliosis,  Huntingdon's  chorea,  multiple  sclerosis,  cerebral 
syphilis,  tabetic  psychoses,  arteriosclerotic  insanity,  brain 
tumor,  cerebral  trauma,  and  cerebral  apoplexy. 

Gliosis  of  Cortex.  —  This  disease,  described  by  Fuerstner, 
presents  numerous  tumorlike  accumulations  of  glia  in  the 
superficial  layers  of  the  cortex  with  the  formation  of  small 
cavities  and  atrophy  of  the  nervous  tissue. 

The  course  of  the  disease  is  chronic,  the  mental  symp- 
toms may  be  of  sudden  onset  with  convulsions  and  irri- 
tability, but  later  there  develops  a  progressive  deterioration 
with  failing  memory,  accompanied  by  disorder  of  speech, 
optic  atrophy,  and  often  tabetic  symptoms.  Diffuse  cere- 
bral sclerosis,  in  which  there  is  an  extensive  increase  of 
the  supportive  tissue,  is  accompanied  by  progressive 
dementia. 

Huntingdon's  Chorea.  —  The  mental  symptons  of  Hun- 
tingdon's chorea  are  distinctive,  consisting  usually  of  a  pro- 
gressive dementia  with  faulty  memory,  weak  judgment, 
paralysis   of   thought,  apathy,  and  irritability.     Patients 

1  Facklam,  Archiv  f.  Pay.,  XXX,  S.  138. 
Zinn,  Archiv  f.  Psy.,  XXVIII,  S.  411. 
Diller,  Am.  Jour.  Med.  Sciences,  Dec,  1889,  April,  1890. 
Hallock,  Jour.  Nerv.  &  Ment.  Dis.,  1898. 
Sinkler,  Med.  Rec,  XLI,  p.  281. 
323 


324  FORMS  OF  MENTAL  DISEASE 

are  unstable  in  employment.  Suicidal  attempts  are  not 
infrequent,  and  occasional  homicidal  tendencies  are  encoun- 
tered. Hallucinations  and  delusions  are  infrequent,  but 
if  present  are  unaccompanied  by  emotion.  Anxious  states, 
outbreaks  of  anger,  restlessness,  sometimes  develop.  The 
choreic  movements  are  intensified  by  any  mental  excitement. 

Physically  the  choreic  movements  of  Huntingdon's 
chorea  differ  from  those  of  acute  chorea  in  that  they  are 
less  extensive  and  less  frequent.  They  involve  the  entire 
trunk,  limb,  head  and  face,  and  are  jerky,  at  times  quick, 
but  often  sluggish.  The  speech  becomes  hesitating,  in- 
distinct, and  indecisive,  while  the  writing  is  rapid  and  hasty. 
The  voluntary  movements  are  rendered  uncertain,  yet  it 
is  surprising  to  observe  how  advanced  cases  maintain 
their  equilibrium  in  walking.  The  arms,  head,  and  trunk 
may  be  drawn  into  various  awkward  positions,  the 
patient  still  keeping  on  his  feet.  The  accompanying 
photographic  group  (Plate  9),  of  three  cases  of  Hunting- 
don's chorea,  shows  the  rapidly  changing  attitudes  of  these 
patients  who  were  trying  to  look  at  the  photographer.  As 
the  disease  advances,  general  muscular  strength  wanes, 
until  in  the  end  stages  the  patients  become  bedridden. 
The  deep  tendon  reflexes  are  usually  exaggerated,  and  the 
muscle  irritability  increased.  Sensation  does  not  suffer. 
Epileptiform  and  apoplectic  attacks  rarely  occur. 

The  course  of  Huntingdon's  chorea  is  slowly  progressive, 
leading  in  the  greater  number  of  cases  to  considerable 
dementia  in  the  course  of  ten  to  thirty  years.  The  mental 
symptoms  usually  appear  coincidently  with  the  first  of  the 
choreiform  movements,  but  they  may  not  appear  for  years ; 
indeed,  the  writer  knows  of  one  case  of  Huntingdon's  chorea 
of  fifteen  years' standing  in  which  the  individual  still  conducts 
successfully  a  large  and  lucrative  law  practice.     While  the 


ORGANIC  DEMENTIAS  325 

underlying  mental  process  is  one  of  progressive  dementia, 
as  described  above,  the  onset  of  the  mental  symptoms 
may  be  sudden  and  of  a  manic  character;  occasionally 
the  symptoms  simulate  the  megalomanic  phase  of  paresis; 
again  the  clinical  picture  may  be  distinctly  depressive  in 
character,  accompanied  by  active  hallucinosis  and  delusion 
formation.  These  various  clinical  states,  however,  are 
usually  only  episodic,  while  deterioration  progresses. 
Marked  dementia  may  have  already  become  evident  before 
these  various  episodes  appear.  Furthermore,  there  is  no 
relationship  between  the  degree  of  choreic  movements  and 
the  mental  symptoms :  either  group  may  be  much  more 
or  much  less  advanced  than  the  other.  Sometimes  the 
choreic  movements  improve  considerably  during  the  course 
of  the  disease. 

Diagnosis.  —  Where  the  mental  symptoms  antedate  or 
predominate  in  the  clinical  picture,  there  may  be  some 
difficulty  in  differentiating  paresis.  In  such  cases  one  must 
depend  upon  the  absence  of  pupillary  disturbances  or  mus- 
cular paresis,  the  presence  of  only  a  hesitancy  in  speech 
with  hastiness  and  tremor  in  writing,  without  defect  in  the 
content  of  speech  and  writing.  In  the  mental  field  the 
emotional  irritability  is  more  disturbed,  and  there  is  pro- 
portionately less  defect  of  memory  and  orientation.  The 
history  of  Huntingdon's  chorea  in  the  antecedents  should 
leave  little  doubt  as  to  the  true  character  of  the  disease. 

The  pathological  anatomy  of  Huntingdon's  chorea  pre- 
sents chronic  leptomeningitis,  with  thickening  of  the  pia 
and  small  cell  infiltration,  general  cerebral  atrophy  with 
shrinking  of  the  cortex,  white  matter,  and  basal  ganglia. 
The  vessels  exhibit  extensive  thickening  of  the  adventitia 
with  increase  in  the  perivascular  spaces,  and  in  places  resid- 
uals of  old  hemorrhages.     In  four  of  the  writer's  cases,  cell 


326  FORMS  OF  MENTAL  DISEASE 

shrinkage  was  observed,  and  in  one  case  also  grave  alter- 
ation. Trabantan  cells  were  present  in  most  sections, 
while  glia  nuclei  were  uniformly  increased  in  the  deeper 
layers  of  the  cortex.  In  all,  vascular  alteration  was  pres- 
ent, with  round  cell  infiltration,  as  well  as  the  presence 
of  free  pigment  about  the  vessels.  In  one  case  there  was 
a  slight  degree  of  ependymitis,  and  in  another,  numerous 
areas  of  thrombotic  softening  were  found  scattered  over  the 
cortex. 

Multiple  Sclerosis.  —  When  the  disease  process  in  multi- 
ple sclerosis  involves'  the  brain,  there  develops  more  or 
less  mental  deterioration.  In  215  cases  reported  by  Berger 
in  1904,  dementia  occurred  in  only  24  cases  (more  than  10  per 
cent).  The  type  of  mental  disturbance  is  usually  that  of 
simple  deterioration  with  failure  of  memory  and  judgment, 
together  with  apathy,  as  seen  in  an  unnatural  complacency 
and  anergy.  Besides  the  emotional  apathy,  there  is  some- 
times present  a  tendency  to  uncontrollable  laughter,  and 
other  emotional  outbursts  of  an  episodic  character.  The 
mental  symptoms,  however,  are  rarely  of  such  pronounced 
character  as  to  bring  the  patient  to  insane  hospitals. 
An  atypical  case  of  multiple  sclerosis  may  be  confounded 
with  dementia  paralytica,  particularly  if  nystagmus, 
scanning  speech,  and  intention  tremor  are  tardy  in  ap- 
pearance or  absent.  The  burden  of  proof  against  dementia 
paralytica  then  rests  upon  the  absence  of  pupillary  dis- 
turbance, and  of  the  characteristic  paretic  speech;  while 
in  the  mental  field  there  is  absence  of  faulty  time  orienta- 
tion and  prominent  defect  of  memory. 

Cerebral  Syphilis.  —  In  cerebral  syphilis  there  are  two 
groups  of  cases:  simple  syphilitic  dementia,  and  syphilitic 
pseudoparesis.  Under  this  term  are  not  included  the 
mental    disturbances    occurring    during    the    early    mani- 


ORGANIC  DEMENTIAS  327 

festations,  such  as  the  occasional  deliria  similar  in  nature 
to  infectious  deliria,  or  the  hysterical  and  neurasthenic 
syndromes,  in  all  of  which  syphilis  seems  to  play  the  role 
only  of  an  exciting  factor.  The  distinctively  characteristic 
syphilitic  psychoses  develop  only  during  the  late  period, 
when  there  is  involvement  of  the  cerebral  vessels  and  the 
development  of  gummata,  vascular  occlusion,  and  malacia. 
The  vessel  alteration  is  typically  syphilitic  and  gives  rise 
to  a  profound  nutritional  disturbance  in  the  cortex.  It  is 
to  be  differentiated  from  that  occurring  in  paresis  by  the 
pathological  fact  that  there  is  only  very  slight  infiltration 
into  the  adventitia  of  the  vessels,  and  mast  cells  are  rare; 
but  there  is  a  marked  proliferation  of  the  intimal  cells, 
with  a  tendency  to  form  vascular  foramina  within  the 
vessel  itself.  The  new  vessel  formation  is  extensive  and 
typical.  The  elastic  fibres  of  the  vessels  tend  to  split  into 
layers,  while  the  vascular  cells  do  not  show  pigmentation. 

In  simple  syphilitic  dementia  there  usually  appears  first, 
defective  memory  and  judgment,  and  some  absent-minded- 
ness, as  well  as  lack  of  insight  into  these  defects.  Coin- 
cident with  the  onset  there  usually  occurs  some  sort  of  an 
apoplectiform  seizure,  which  may  be  either  of  a  mild  or 
a  severe  grade.  Emotionally  there  is  a  slight  degree  of  ela- 
tion. The  patients  are  fond  of  boasting  of  their  strength 
and  ability,  and  plan  extensively  for  the  future.  If  there 
happens  to  be  present  some  feeling  of  illness,  they  are 
confident  of  recovery.  But  more  prominent  still  is  the 
greatly  increased  emotional  irritability,  which  often  leads 
to  strife  and  outbursts  of  passion.  Delusions  of  influence 
and  reference  are  sometimes  present,  also  ideas  of  oppres- 
sion and  mistreatment,  to  which  are  ascribed  sordid  mo- 
tives; but  such  delusional  ideas  are  transient  and  rarely 
elaborated.    Volitionally  there  is  evident  weakness  of  will, 


328  FORMS  OF  MENTAL  DISEASE 

as  shown  in  their  tractability  and  fickleness.  They  tend  to 
be  thoughtless,  disorderly  in  their  work,  neglect  important 
for  unimportant  matters,  and  do  all  sorts  of  extravagant 
things.     Finally,  there  is  a  striking  susceptibility  to  alcohol. 

The  course  of  the  disease  is  usually  slow,  although  it  may 
soon  reach  a  stage  of  quiescence,  with  subsidence  of  the 
prominent  symptoms.  Recovery  is  rare,  in  spite  of  anti- 
syphilitic  treatment,  because  the  cortex  has  become  ex- 
tensively involved.  There  are  occasional  exacerbations. 
Physically,  the  onset  is  usually  with  an  apoplectiform  attack ; 
and  as  the  result  of  this  there  may  be  residual  hemiplegia 
or  monoplegia,  sometimes  paresis  of  the  eye  muscles,  some 
slight  fault  of  articulation,  and  also  complete  or  reflex 
iridoplegia. 

This  group  of  cases  should  also  include  that  form  of 
progressive  deterioration  appearing  in  youth  which  arises 
from  congenital  syphilis  and  is  accompanied  by  forms 
of  paralysis.  The  pathological  distinction  between  these 
cases  and  juvenile  paresis  is  that  in  the  former  there  exists 
only  the  vascular  lesions  characteristic  of  syphilis.  How- 
ever, Meyer  and  Kaplan  have  described  some  cases  in  which 
there  was  a  mixture  of  paretic  and  syphilitic  lesions. 

To  this  group  also  should  be  added  the  cases  described 
by  Barrett,1  Bechterew,2  and  Jurgens,3  in  which  the  lesion  is 
one  of  disseminated  syphilitic  encephalitis. 

In  Barrett's  case  the  deterioration  was  very  rapid,  leading 
to  complete  dementia  and  death  within  two  months,  while 
in  the  case  of  Bechterew  the  course  of  the  disease  extended 
through  two  years. 

1  Amer.  Jour,  of  Med.  Sc,  Vol.  129,  p.  390. 

a  Handbuch    der   path.  Anat.  des   Nervensystems.      Flatan-Jacobsohn- 

Minor. 
5  Ref.  Oppenheim,  Sypbilitische  Erkrank  des  Gehirns. 


ORGANIC  DEMENTIAS  329 

Syphilitic  pseudoparesis  includes  those  cases  of  cerebral 
syphilis  which  present  pronounced  mental  symptoms,  in 
addition  to  the  evidences  of  focal  brain  lesions.  The  grada- 
tions between  simple  syphilitic  dementia  and  pseudopare- 
sis are  so  imperceptible  in  many  cases  that  some  authors 
do  not  attempt  a  differentiation,  but  describe  both  groups 
under  cerebral  syphilis.  The  onset  of  pseudoparesis,  as  in 
simple  syphilitic  dementia,  may  be  with  paralytic  attacks. 
The  attacks  may  be  only  syncopal,  or  aphasiform  and  of 
short  duration,  or  there  may  be  loss  of  consciousness  with 
more  or  less  severe  paralysis.  Such  attacks  may  antedate 
many  months  the  mental  symptoms,  or  they  may  be  tardy 
in  appearing  and  sometimes  they  never  develop.  Of  the 
mental  symptoms,  despondency  is  the  first  to  appear,  in 
which  either  hypochondriasis  or  apprehensiveness  predomi- 
nate. The  patients  feel  stupid,  the  food  does  not  agree 
with  them,  they  are  self-accusatory,  fearful,  and  speak 
of  infidelity.  There  is  a  change  of  character,  and  they  become 
indifferent,  forgetful,  confused  in  thought;  at  other  times 
they  are  irritable,  excitable,  and  aggressive.  Even  delirious 
excitement  may  develop.  Hallucinations  are  usually 
present  and  often  very  prominent,  mostly  of  hearing, 
though  sometimes  of  sight  and  smell.  The  megalomanic 
delusions  so  characteristic  of  paresis  predominate  and  with 
this  there  is  emotional  elation  and  a  tendency  to  face- 
tiousness,  although  some  patients  are  irritable,  suspicious, 
and  hostile.  Many  patients  are  productive  both  in  speech 
and  writing,  exhibiting  incoherence  and  even  neologisms; 
others  are  inactive,  sleepy,  and  reticent,  and  again  others 
vary  from  one  state  to  another.  Physically,  besides  the 
residuals  of  syphilitic  infection,  and  of  the  earlier  apoplecti- 
form attacks,  such  as  hemiparesis,  hemianopsia,  and  para- 
phasia, etc.,  there  may  be  present  optic  atrophy,  an  increase, 


330  FORMS  OF  MENTAL  DISEASE 

absence  or  weakening,  and  particularly  inequality  of  the 
tendon  reflexes,  and  complete  or  almost  complete  loss  of 
the  light  reaction  of  one  or  both  pupils.  Speech  and  writing, 
however,  show  insignificant  changes. 

The  course  of  the  disease  is  slow,  leading  regularly  to 
a  considerable  degree  of  dementia.  Some  patients  continue 
orderly  and  are  able  to  live  at  home;  they  possess  the 
ability  to  read  and  amuse  themselves,  and  follow  up  a  simple 
daily  routine,  but  are  wholly  incapable  of  profitable  employ- 
ment, lack  insight  into  their  condition,  and  are  thoughtless 
of  the  future.  They  continue  oriented,  but  memory  for 
events  of  the  psychosis  and  sometimes  even  for  earlier  life 
is  faulty.  The  hallucinations  and  delusions  tend  to  reap- 
pear ;  these  are  never  modified  but  only  forgotten. 

In  the  severer  cases  the  dementia  is  more  profound; 
the  patients  are  continuously  confused,  maintaining  their 
various  expansive  and  persecutory  delusions,  exhibiting 
restlessness,  excitement,  and  aggressiveness,  or  they  may  be 
childishly  good-natured  and  thoroughly  tractable.  Tran- 
sitory conditions  of  profound  stupidity  and  confusion  arise. 
Paralytic  attacks,  either  epileptiform  or  syncopal,  with  or 
without  residuals,  reappear  with  more  or  less  regularity 
throughout  the  course  and  may  terminate  the  disease. 
The  course  of  the  symptoms  may  not  be  as  progressive, 
but  after  reaching  a  certain  stage  remain  unchanged  a 
long  time,  until  an  exacerbation  or  some  intercurrent  dis- 
ease causes  death. 

The  pathology  of  pseudoparesis  exhibits  the  following 
syphilitic  lesions:  meningitis,  foci  of  malaria,  gummata, 
and  particularly  the  syphilitic  vascular  lesions.  Through- 
out the  entire  cortex  there  is  a  hyperplasia  of  glia  cells, 
so  much  so  that  in  places  the  "gliarasen"  of  Nissl  is 
found,  indicating  a  profound  degeneration  of  nerve  cells. 


ORGANIC  DEMENTIAS  331 

The  nerve  fibres,  however,  are  not  much  involved,  and  there 
is  also  very  little  development  of  glia  fibres,  and  hence 
practically  no  reduction  of  the  cortex.  Regressive  changes 
may  be  seen  in  many  neuroglia  cells.  In  the  deeper  layers 
of  the  cortex  there  is  a  large  increase  of  small  round  glia 
nuclei.  The  large  vessels  are  deeply  stained  (NissPs  stain) 
and  the  perivascular  spaces  are  enlarged,  although  there  is 
no  infiltration  of  the  adventitia  similar  to  what  one  finds 
in  dementia  paralytica.  The  small  vessels  are  greatly  in- 
creased in  number,  dilated,  and  present  many  anastamoses, 
appearing  everywhere  to  be  overlaid  with  glia  cells. 
According  to  Nissl,  this  proliferation  does  not  take  place  by 
budding  as  in  paresis,  but  by  the  formation  of  new  vessel 
openings  through  the  thickened  endothelium  among  the 
numerous  layers  of  the  elastic  coat.  The  muscular  coat 
disappears.  Finally,  rod  cells  are  very  rarely  found.  These 
lesions  extend  throughout  the  cortex,  but  to  a  varying  de- 
gree, in  places  being  almost  imperceptible.  They  are  always 
more  marked  in  the  superficial  layers  of  the  cortex.  Occa- 
sionally small  old  or  fresh  hemorrhagic  foci  are  found. 

The  similarity  of  pseudoparesis  to  general  paresis  is  so 
striking  that  the  differential  diagnosis  is  very  difficult  and 
depends  mostly  upon  the  presence  and  persistence  of  the 
residuals  of  the  paralytic  attacks.  These  often  exist  from 
the  onset,  which  is  not  true  in  paresis.  The  characteristic 
paretic  faults  of  speech  and  writing,  with  the  aphasia  and 
stumbling  over  syllables,  the  transposition  and  the  repetition 
of  syllables  and  letters,  are  absent,  as  well  as  the  disturb- 
ances of  the  sensibility  to  pain.  Memory  is  better  than  in 
paresis,  and  except  in  the  very  bad  cases,  orientation  is 
preserved,  i.e.  names  of  persons  are  recalled  and  the  pa- 
tients remember  striking  incidents  in  their  environment, 
and  also  take  some  pride  in  neatness  and  order.    At  the 


332  FORMS  OF  MENTAL  DISEASE 

onset,  when  differentiation  is  most  difficult,  one  observes 
that  in  paresis  the  memory  defect  is  out  of  proportion  to  the 
disorder  in  the  rest  of  the  mental  life,  and  hallucinations 
are  less  prominent  than  in  pseudoparesis.  The  treatment  of 
pseudoparesis  presents  but  little  hope,  although  the  few 
favorable  cases  following  antisyphilitic  treatment  warrant  a 
trial  in  all  (see  p.  319). 

Tabetic  Psychoses.  —  In  most  cases  where  mental  symp- 
toms develop  during  the  course  of  tabes,  the  disease  ter- 
minates as  paresis,  but  there  are  a  few  cases  which  never 
become  paretic.  Very  mild  mental  symptoms  often  appear 
during  the  early  stages  of  tabes,  i.e.  some  fault  of  memory, 
and  an  increased  sense  of  fatigue,  but  more  especially  a 
change  in  disposition.  Many  patients  become  gloomy  and 
hopeless,  and  have  forebodings  and  fears,  but  others  are 
cheerful,  happy,  and  confident,  sometimes  reminding  one 
of  the  feeling  of  well-being  of  the  paretic. 

The  characteristic  tabetic  psychosis,  however,  is  an  acute 
hallucinosis  with  some  excitement  resembling  the  acute 
alcoholic  hallucinosis.  The  onset  of  the  hallucinosis  is  sud- 
den, with  hallucinations  of  hearing,  accompanied  by  some 
anxiety  and  restlessness.  Later  hallucinations  of  the 
other  senses  appear.  The  hallucinations  are  of  a  threaten- 
ing, disturbing  type :  such  as  the  voices  of  relatives  calling 
for  help,  threats  against  their  lives,  the  odor  of  sulphur, 
or  the  sensation  of  electricity,  to  all  of  which  the  patients 
react.  Orientation  remains  clear.  The  duration  of  the 
attack  may  be  for  a  few  weeks  or  several  months,  when  the 
symptoms  often  disappear  suddenly.  There  may  be  remis- 
sions. 

The  psychosis  may  resemble  a  short  hallucinatory  de- 
lirium, or  it  may  simulate  a  chronic  psychosis  with 
hallucinations  and  paranoid  delusions,  both  of  persecution 


ORGANIC  DEMENTIAS  333 

and  grandeur.  Again  all  of  these  different  forms  may- 
represent  different  clinical  stages  of  the  same  disease  pro- 
cess, similar  to  the  acute  and  chronic  disease  pictures  which 
one  sees  in  paresis,  alcoholism,  and  dementia  praecox.  In 
some  of  the  chronic  cases  there  is  a  similarity  to  syphilitic 
pseudoparesis.  Besides  these  forms  of  tabetic  psychoses 
there  may  develop  in  tabes  the  manic-depressive  syndrome, 
the  catatonic  or  the  senile  psychoses.  The  tabetic  psychoses 
are  differentiated  from  the  forms  of  paresis  by  the  fact  that 
the  disease  process  is  not  progressive.  The  grade  of  dete- 
rioration remains  at  a  standstill,  and  furthermore,  attention 
and  memory  is  not  disturbed  to  the  degree  that  it  is  in 
paresis. 

Arteriosclerotic  Insanity.1 — Arteriosclerotic  changes  in 
the  brain  are  very  common  in  the  senile  period  of  life,  yet 
it  is  doubtful  if  one  is  justified  in  considering  them  only  as 
evidence  of  early  senility,  particularly  in  view  of  the  fact 
that  extensive  arteriosclerosis  may  exist  without  accom- 
panying mental  impairment.  One  must  conclude  either 
that  the  vascular  disease  in  arteriosclerotic  insanity  is 
not,  in  spite  its  great  similarity,  identical  with  that  occur- 
ring in  normal  senility,  or  that  in  the  former  case  the  vas- 
cular change  is  an  accompaniment  of  only  secondary  impor- 
tance in  a  disease  process  which  is  highly  destructive  of 
nerve  tissue.  The  varying  extent  of  the  vessel  change, 
especially  whether  it  involves  the  smaller  or  greater  vessels, 
may  account  for  the  absence  or  presence  of  mental  mani- 
festations. 

1  Alzheimer,  Allgem.  Zeitschr.  f .  Psy.,  LI,  809 ;  idem,  LIII,  863 ;  idem, 

LIX,  695. 
Binswanger,  Berl.  Klin.  Wochenschr,  1894,  49. 
Alzheimer,   Histologische  und   Histopathologische    Arbeiten   iiber   die 

Grosshirurinde-Nissl,  Jena,  1904. 


334  FORMS  OF  MENTAL  DISEASE 

This  psychosis  appears  about  the  sixtieth  year;  yet  some 
cases  develop  before  fifty,  but  in  the  latter  instance 
there  is  usually  present  a  strong  hereditary  tendency  to 
vascular  disease.  Alcoholism  and  syphilis  may  be  regarded 
as  etiological  factors.  When  the  disease  occurs  later  in 
life,  the  arteriosclerosis  may  be  associated  with  the  charac- 
teristic senile  changes  of  the  nervous  tissue  which  are  de- 
pendent upon  the  vascular  changes.  Alzheimer  speaks 
of  these  cases  as  "  Senile  Decay."  This  form  of  disease 
attacks  especially  the  cortical  vessels  that  pass  in  from 
the  pia,  leading  to  the  formation  of  deep  wedge-shaped 
foci  with  destruction  of  the  nerve  tissue  and  an  increase 
of  glia. 

Pathological  Anatomy. — There  is  regularly  found,  besides 
the  evidences  of  general  arteriosclerosis,  cardiac  involve- 
ment, either  cardiac  hypertrophy  or  dilation,  and  inter- 
stitial nephritis.  The  cerebral  vessels  are  thickened  and 
rigid,  the  dura  and  pia  thickened,  the  latter  being  cloudy, 
and  the  entire  brain  is  more  or  less  atrophied.  Several 
areas  of  hemorrhagic  softening,  either  fresh  or  old,  are  usually 
found  in  the  cortex,  and  the  ventricles  are  much  dilated. 
Microscopically,  the  numerous  disease  foci  are  found, 
especially  along  the  path  of  the  altered  vessels.  In  these 
areas  the  nervous  tissue  has  disappeared,  being  replaced  by 
a  luxuriant  growth  of  neuroglia,  which  shows  little  or  no 
tendency  to  regressive  changes.  The  blood  vessels,  in 
addition  to  the  usual  arteriosclerotic  changes,  namely, 
a  splitting  and  swelling  of  the  elastica,  thickening  of  the 
walls,  and  regressive  changes  in  the  muscularis  and  adven- 
titia,  also  show  a  tendency  to  hyaline  infiltration.  In  the 
lymph  spaces  there  is  increase  of  connective  tissue,  pig- 
mentation, and  granular  cells.  Comparing  the  normal  with 
the  arteriosclerotic  cortex,  as  seen  in  Figures  1  and  2,  Plate  10, 


lK*     v 


4-. 


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|         *  .  *      ■  "*<*.       ■                       1 : 

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r  ,  ,,,-v  „:  ♦*v^v    ,VV' 

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>.  i.T.  y  ;,'  *••■■  -w    •■»■* 

,  '.: ••*  -.  ,  ,"    v,f  ;   «•,'  .,  K'*»' 

,  '   * '  .'       *•  *     >,.•'«•'•,      <        »,  4   ' 

\      ,     *  4>  .'    "'\          i*       •  .      *    *             .     *      ,' 

»5r<V,Vfi     *•"••'.'■ 

k,  VV   *J 4i',  n.    .  *•  -•  ■ 

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t  \*  >*  *k<    i\*i    »    i' V   "*  *    .,■* 

Plate  10 
Fig.  1 — Arteriosclerotic  cortex.     Fig.  2  —  Normal  cortex. 


ORGANIC  DEMENTIAS  335 

it  is  apparent  how  extensive  the  degeneration  of  cells  has 
been.  The  few  remaining  nerve  cells  present  a  high-grade 
alteration  in  the  intercellular  tissue.  Deeply  stained  glia 
nuclei  are  scattered  everywhere,  mostly  surrounded  by  a 
clear  space,  and  gathered  in  groups,  particularly  about 
vessels.  The  vessels  themselves,  both  large  and  small, 
present  few  nuclei,  are  hyaline  and  greatly  thickened.  Some 
vessels  appear  to  have  a  double  lumen,  which  is  very  fre- 
quently found  in  the  arteriosclerotic  cortex.  The  disease 
process  is  not  evenly  distributed  throughout  the  entire 
cortex,  as  there  are  foci  where  only  moderate  changes  are 
noted.  Further,  one  cannot  judge  of  the  extent  of  the 
vascular  change  in  the  cortical  vessels  by  the  appearance 
of  the  larger  vessels  in  the  pia,  as  the  latter  may  be  much 
altered,  while  the  former  show  little  change.  The  nerve 
fibres,  both  in  the  cortex  and  in  the  white  matter,  show 
changes  proportionate  to  the  vascular  disease.  There 
usually  are  numerous  cavities  in  the  white  matter,  partic- 
ularly along  the  line  of  the  vessels.  This  condition,  called 
etat  crible,  presents  a  very  characteristic  picture.  Where 
this  state  is  very  pronounced  and  where  the  subcortical 
region  is  more  involved  than  the  cortex,  it  has  been  called, 
by  Binswanger,  chronic  subcortical  encephalitis.  Clini- 
cally these  cases  are  characterized  by  very  many  limited 
focal  symptoms  and  a  very  pronounced  dementia.  The 
pyramidal  tracts  may  show  atrophy  in  the  pons  and  medulla. 
Symptomatology.  —  The  first  symptoms  of  arteriosclerotic 
insanity  consist  of  a  diminution  of  energy,  and  forgetful- 
ness.  The  patients  tire  easily,  lack  the  characteristic  fresh- 
ness and  energy  for  work.  They  not  only  hesitate  to 
undertake  anything  new,  but  lack  ability  to  do  original 
work.  Emotionally,  they  are  easily  depressed,  disheartened, 
at  times  whining;  again,  they  may  be  irritable,  and  sub- 


336  FORMS  OF  MENTAL  DISEASE 

ject  to  emotional  outbursts.  Emotional  instability  is  apt 
to  be  present,  as  seen  in  rapid  changes  from  one  emotional 
state  to  another  and  in  frequent  weeping  and  laughing. 
Patients  are  forgetful  and  flighty,  and  mix  up  their  work. 
There  is  always  present  a  very  definite  feeling  of  illness 
that  may  even  border  on  hypochondriasis.  This  may  lead 
to  suicidal  attempts.  Under  the  influence  of  alcohol  or 
some  emotional  stress  a  moderate  degree  of  dazedness  may 
develop.  Later  in  the  course  of  the  disease  delusions  of 
reference  and  particularly  of  infidelity  are  prone  to  appear. 

The  prominent  physical  symptoms  are  more  or  less 
pronounced  attacks  of  dizziness,  syncope,  or  even  convulsive 
attacks,  which  may  be  accompanied  by  paraphasic  disturb- 
ances, disturbances  of  sensation,  paresis,  and  even  paralysis. 
Residuals  of  these  attacks  usually  persist.  Pupillary 
reaction  is  retained,  or  at  most  is  only  slightly  sluggish. 
The  usual  vascular  and  cardiac  symptoms  of  arterio- 
sclerosis are  present,  and  there  is  albumen  in  the  urine. 

These  symptoms  may  remain  at  a  standstill  for  years, 
particularly  if  the  patient's  method  of  living  is  carefully 
regulated,  but  sooner  or  later  apoplexy  appears  with  its 
residuals.  With  each  recurring  attack  there  is  further  de- 
mentia, in  which  attention  and  memory  suffer.  Later 
there  develops  complete  disorientation,  and  indifference, 
but  at  times  there  is  childish  irritability  and  at  others 
happiness.  Finally  deterioration  becomes  so  pronounced 
that  they  have  to  be  cared  for  and  fed  like  little  children. 
Not  all  cases  develop  this  degree  of  deterioration;  indeed, 
there  may  be  all  grades  of  dementia.  Aphasia,  agraphia, 
apraxia,  and  asymbolism,  also  word  and  mind  blindness, 
are  frequent  complications  of  these  vascular  lesions,  which 
tend  to  make  the  mental  deterioration  appear  even  greater 
than  it  really  is.    There  are  old  apoplectics  of  ten  years' 


ORGANIC  DEMENTIAS  337 

or  more  duration  who  present  only  an  increased  sense  of 
mental  fatigue,  ill-humor,  and  some  weakness  of  will, 
rendering  them  particularly  susceptible  to  outside  influences. 
In  such  cases  the  vascular  lesions  are  supposed  to  be  more 
circumscribed  or  to  have  come  to  a  standstill. 

There  is  a  group  of  cases  of  arteriosclerotic  insanity  that 
deserve  special  attention;  namely,  those  comprising  the 
severe  progressive  form.  These  cases  are  characterized 
by  a  very  rapid  course  leading  to  profound  dementia  and 
death.  The  disease  usually  begins  with  an  apoplectiform 
attack,  although  there  may  have  been  prodromal  headaches, 
some  forgetfulness,  and  lack  of  energy.  Following  this 
there  develops  a  condition  of  marked  anxiety  and  appre- 
hensiveness,  sometimes  with  pronounced  delusions  of  a 
persecutory  nature,  occasionally  hallucinations  and  delusions 
of  self-accusation.  The  patients  are  usually  clouded  and 
confused,  so  much  so  that  they  do  not  even  understand  what 
goes  on  about  them  or  what  is  said  to  them.  They  are 
irritable,  restless,  aggressive,  wandering  about,  attempt 
escape,  trying  to  jump  from  the  window,  or  commit  suicide. 
Nocturnal  restlessness  is  particularly  marked.  Nutrition 
and  sleep  suffer  profoundly.  There  regularly  develop  for 
longer  or  shorter  periods  conditions  of  even  greater  be- 
wilderment and  more  active  restlessness.  The  patients 
become  even  more  clouded,  so  that  they  perceive  practically 
nothing  and  their  attention  cannot  be  fixed.  Obstacles 
placed  before  them  are  not  perceived  or  are  handled  in  a 
wholly  automatic  manner.  They  will  not  avoid  a  test 
needle,  although  they  wince  from  pain.  Emotionally,  they 
manifest  lack  of  feeling,  although  occasionally  there  may  be 
some  anxiety  or  again  some  elation.  Insight  is  absent. 
The  patients  present  an  almost  incessant,  motiveless 
activity,  and  they  have  no  care  of  themselves.    The  speech 


338  FORMS  OF  MENTAL  DISEASE 

is  usually  wholly  incoherent,  sort  of  babbling,  and  often 
unintelligible.  Such  mental  states  usually  end  in  death. 
Yet  the  excitement  may  disappear,  leaving  the  patient 
in  a  condition  of  dementia  which  then  becomes  gradually 
progressive.  The  patients  are  wholly  listless,  disoriented, 
and  comprehend  only  the  simplest  questions.  They  have 
neither  the  energy  to  busy  themselves  nor  the  interest  to 
mingle  much  in  their  environment.  There  is  great  emotional 
weakness  and  the  patients  laugh  and  cry  very  easily;  even 
spasmodic  laughing  and  crying  may  exist.  In  spite  of 
their  great  deterioration,  they  may  be  able  to  solve  simple 
mathematical  problems,  and  not  only  recognize  the  members 
of  their  family,  but  derive  some  enjoyment  from  their  visits. 
Physically,  in  addition  to  the  residuals  of  the  apoplectic 
attacks,  in  which  paraphasic  disturbances  are  apt  to  be 
prominent,  there  is  also  a  peculiar  impediment  of  speech 
which  may  sometimes  lead  to  genuine  scanning.  The 
writing  also  presents  marked  changes.  Individual  letters 
are  barely  legible,  even  though  ataxia  is  not  evident.  The 
patients  lose  their  ability  to  write  the  single  strokes  into  a 
complete  word.  In  the  words  that  can  be  read  omissions 
are  found.  These  faults  of  writing  are  present  from  the 
beginning  and  may  be  regarded  as  a  sign  of  rapid  fatigue. 
The  pupillary  reaction  is  always  maintained,  although  some- 
times it  is  sluggish.  The  entire  duration  of  the  disease  is 
about  four  years,  though  there  are  cases  of  six  to  seven 
years'  duration ;  and  again,  some  cases  run  a  course  of  only 
a  few  months.  The  prognosis  in  any  case  is  always  in- 
fluenced by  the  general  physical  condition,  especially  the 
condition  of  the  heart,  lungs,  and  kidneys,  as  well  as  the 
age  of  the  patient. 

The  diagnosis  of  arteriosclerotic  insanity  may  be  difficult, 
particularly  the  differentiation  from  paresis  occurring  in 


ORGANIC  DEMENTIAS  339 

late  life.  In  the  first  place,  it  must  be  remembered  that 
paresis  is  a  diffuse  lesion  of  the  cortex,  while  in  arterio- 
sclerotic insanity  there  are  many  scattered  foci.  Therefore, 
we  find  in  paresis  that  the  general  psychic  alteration  is 
more  prominent  than  the  physical  signs.  Paretics  are 
usually  clouded  and  exhibit  loss  of  judgment  before  the 
physical  symptoms  appear,  while  in  arteriosclerotic  insan- 
ity the  apoplectiform  attacks  are  very  often  the  starting- 
point  of  the  psychical  disturbances.  In  arteriosclerotic 
insanity  disturbances  of  perception  are  more  striking  than 
disturbances  of  memory,  while  in  paresis  both  are  equally 
impaired.  Emotionally,  the  paretic  shows  greater  elation 
or  depression ;  while  the  arteriosclerotic  patient  is  usually 
indifferent  and  apathetic,  or  he  presents  either  hypochon- 
driacal despondency  or  indefinite  fear.  The  great  elation 
of  some  paretics  and  the  profusion  of  delusions  is  wholly 
lacking  in  the  arteriosclerotic  condition.  Fabrication,  al- 
though a  prominent  symptom  in  paresis,  is  seldom  indulged 
in  by  the  arteriosclerotic  patient,  and  then  it  is  of  an 
altogether  different  character,  being  meagre  and  without 
the  florid  embellishments  of  the  paretic  fabrication.  These 
patients  also  present  in  a  marked  degree  lack  of  mental 
power;  yet  at  times  they  suddenly  surprise  one  with  their 
knowledge,  although  at  other  times  they  appear  much  de- 
mented. There  does  not  appear  to  be  such  a  complete  loss 
of  mental  power  as  in  paresis,  but  an  inability  to  control  it, 
and  corresponding  to  this  there  is  a  greatly  increased  sense 
of  fatigue  which  is  not  present  in  paresis.  Finally,  in  spite 
of  the  apparent  great  dementia,  many  of  the  arteriosclerotic 
patients  remain  oriented  to  the  end,  recognize  their  relatives 
and  enjoy  their  visits,  having  good  insight  into  their  physical 
and  mental  helplessness. 
Further,  physically  there  is  a  marked  contrast  between 


340  FORMS  OF  MENTAL  DISEASE 

the  paretic  and  arteriosclerotic  symptoms.  In  the  ar- 
teriosclerotic state  the  physical  symptoms  are  prominent ; 
such  as  persistent,  well-defined  paralyses  with  spasms, 
contractures,  aphasia,  asymbolism,  word  blindness,  mind 
blindness,  hemianopsia,  and  astereognosis.  The  speech 
disturbance  is  more  of  the  type  that  arises  from  paralysis, 
while  in  writing,  simple  omissions  are  more  prominent  than 
the  ataxia  and  the  transposition  of  syllables  seen  in  paresis. 
Very  often  perseveration  is  present.  The  pupils  remain 
normal.  The  presence  of  arteriosclerotic  changes  elsewhere 
in  the  body  point  to  a  similar  condition  in  the  brain,  but 
the  former  is  no  sure  criterion  of  the  extent  of  the  brain 
involvement.  In  the  earliest  stages  of  the  disease,  when  the 
diagnosis  may  be  most  difficult,  the  predominance  of  the 
general  physical  symptoms  over  the  mental  symptoms, 
the  latter  of  which  are  more  apparent  to  the  patient  himself 
than  to  the  friends,  always  favors  a  diagnosis  of  arterio- 
sclerotic insanity. 

Simple  syphilitic  dementia  may  be  differentiated  from 
arteriosclerotic  insanity  only  with  difficulty,  particularly 
in  the  early  stages.  In  the  syphilitic  psychosis,  we  per- 
ceive a  slower  development  of  the  'symptoms,  and  the  dis- 
turbances of  memory  and  perception  are  less  pronounced, 
while  the  focal  symptoms  are  more  uniform,  less  manifold 
and  variable  than  in  the  arteriosclerotic  condition ;  again, 
the  tendency  to  oculomotor  disturbance,  of  optic  disorder, 
and  paralysis  of  the  pupils  is  of  importance  as  well  as  the 
knowledge  of  syphilitic  disease  elsewhere  in  the  body. 
In  differentiating  pseudoparesis  we  find  that  the  course  is 
not  as  progressive  as  in  arteriosclerotic  insanity,  while 
the  hallucinations  and  delusions  are  not  nearly  as  promi- 
nent and  are  often  absent  in  arteriosclerotic  insanity. 
The  degree  of  deterioration  does  not  become  as  great; 


ORGANIC  DEMENTIAS  341 

memory  is  better,  orientation  is  retained,  and  the  patients 
continue  conscious. 

The  treatment  of  arteriosclerotic  insanity  demands,  first 
of  all,  rest,  freedom  from  occupation,  avoidance  of  excite- 
ment and  all  articles  of  diet  that  interfere  with  the  vascular 
system;  namely,  alcohol,  coffee,  tea,  and  much  tobacco. 
Forms  of  excessive  exercise  should  also  be  avoided,  as 
swimming,  rowing,  bicycle  riding,  etc.  It  is  doubtful  if 
the  administration  of  potassium  iodide  or  the  employment 
of  foods  containing  calcium  have  any  beneficial  effect. 
In  the  later  stages  of  the  disease  the  patients  are  apt  to 
become  bedridden,  and  require  very  careful  nursing. 

Cerebral  Tumor.  —  In  cerebral  tumor  all  cases  do  not 
develop  mental  symptoms.  Of  318  cases  Gianelli  discovered 
but  299  that  developed  a  psychosis.  If  the  cortex  is  not 
much  involved  or  if  the  tumor  is  of  slow  growth,  mental 
symptoms  may  not  appear.  On  the  other  hand,  they  may 
develop  where  there  is  a  small  circumscribed  growth,  but 
in  such  cases  there  is  always  the  possibility  of  chemical 
or  other  destructive  agencies  extending  over  a  broader 
area.  If  the  growth  is  of  considerable  size,  mental  symp- 
toms are  sure  to  appear.  According  to  Schusters,  tumors 
of  the  hypophysis  in  about  two-thirds  of  the  cases  develop 
a  psychosis,  of  the  cerebellum  in  one-third  of  the  cases,  and 
of  the  stem  in  one-fourth  of  the  cases. 

In  these  cases  the  influence  upon  the  cortex  may  arise 
from  increase  of  the  general  pressure  and  interference 
with  the  blood  supply,  both  venous  and  arterial.  In  tumors 
of  the  corpus  callosum  the  destruction  of  the  association 
fibres  beween  the  two  hemispheres  has  some  effect  upon  the 
mentality.  In  general,  then,  the  effect  of  tumors  outside  the 
cortex  upon  the  mental  processes  depends  upon  their  size. 
This  theory  receives  some  support  from  the  fact  that  exten- 


342  FORMS  OF  MENTAL  DISEASE 

sive  tumors,  involving  even  the  cortex,  may  run  their  course 
without  mental  symptoms,  if  the  tissue  is  gradually  destroyed, 
and  not  put  under  pressure ;  while,  on  the  other  hand,  even 
small  tumors  of  the  brain  are  often  observed  to  produce 
pronounced  mental  symptoms  because  they  exert  either 
local  or  general  pressure.  Schuster  observes  in  his  ex- 
perience that  those  tumors  lying  nearest  the  cortex  produce 
far  more  mental  symptoms  than  those  lying  at  a  distance. 
The  latter  cause  only  a  simple  progressive  disappearance 
of  the  mental  activity,  indicating  a  cortical  paralysis, 
while  the  former  indicate  signs  of  irritation. 

The  mental  symptoms  of  brain  tumor  are  naturally  quite 
varied.  Schuster  in  about  fifty-six  per  cent  of  775  cases  of 
brain  tumor  accompanied  by  mental  symptoms  finds  that 
these  symptoms  consist  of  a  gradually  progressive  men- 
tal weakness.  The  patients  become  sleepy,  inattentive, 
forgetful,  unproductive  in  thought,  indifferent,  fatigue 
easily,  and  are  without  either  their  characteristic  energy  or 
facility  for  prolonged  work.  Mental  application  calls  for 
an  unusual  effort.  They  exhibit  a  degree  of  drowsiness  and 
stupidity  which  may  even  extend  to  coma.  In  addition 
to  this,  there  develop  the  various  symptoms  indicative 
of  tissue  irritation  and  destruction,  the  character  of  which 
depends  somewhat  upon  the  situation  and  growth  of  the 
tumor,  such  as  apoplectiform  attacks,  convulsions,  aphasia, 
hemianopsia,  etc.  Where  these  symptoms  are  slight  or 
altogether  absent,  the  picture  may  appear  very  much  like 
a  case  of  paresis  of  the  demented  form.  In  such  cases  the 
differentiation  depends  upon  the  absence  of  reflex  pupillary 
disturbance  and  the  absence  of  speech  disorder. 

Other  symptoms  emphasized  by  Schuster  are  greatly 
increased  irritability  with  transitory  periods  of  excitement, 
less  often  periods  of  despondency  with  delusions  of  per- 


ORGANIC  DEMENTIAS  343 

secution  and  self -accusation.  Tumors  of  the  dorsal  regions 
of  the  brain  are  apt  to  be  accompanied  by  delirious  states 
with  pronounced  hallucinosis,  although  mental  symptoms 
accompanying  tumors  of  this  region  are  less  frequent  than 
in  tumors  of  the  frontal  lobes. 

Occasionally  in  brain  tumors  there  exists  a  condition 
of  elation,  even  with  distractibility  of  attention,  productive- 
ness, flight  of  ideas,  and  some  increased  activity ;  but  more 
frequently  there  exists  a  condition  of  childish  happiness, 
with  a  tendency  to  joking  and  punning.  This  mental 
state  Schuster  finds  more  characteristic  of  tumors  of  the 
frontal  lobes.  Finally  the  hysterical  syndrome  may  exist 
in  brain  tumor. 

The  differential  diagnosis  in  this  state  as  well  as  in  all  of 
those  already  mentioned  depends  almost  wholly  upon 
the  presence  and  character  of  the  physical  symptoms, 
indicative  of  focal  lesions.  As  regards  treatment,  one  should 
resort  to  anti-syphilitic  treatment  in  cases  of  suspected 
syphilitic  gumma,  and  to  surgical  interference  where  the 
location  of  the  tumor  is  suitable  for  such  procedure.  In 
recent  years  there  is  a  gowing  tendency  to  operate  in  all 
cases  of  cerebral  tumor,  if  only  for  the  temporary  relief 
of  distressing  symptoms. 

Brain  Abscess. — Brain  abscess  may  be  unaccompanied 
by  mental  symptoms,  particularly  if  it  be  of  slow  develop- 
ment. In  recent  traumatic  abscesses  stupor  is  a  prominent 
symptom.  The  patients  are  completely  disoriented,  and 
do  not  comprehend  what  is  said  to  them.  They  are  restless, 
resistive,  and  sometimes  in  a  dreamy,  delirious  state.  Be- 
sides this,  there  may  develop  catalepsy,  aphasia,  epilepsy, 
slow  pulse,  Cheyne-Stokes  breathing,  and  other  signs  of 
irritation. 

Cerebral  Apoplexy.  —  The  mental  symptoms  of  cerebral 


344  FORMS  OF  MENTAL  DISEASE 

hemorrhage,  embolism,  and  thrombosis  usually  depend  in 
small  measure  only  upon  the  focal  disorder.  Immediately 
following  the  apoplexy  the  patients  are  usually  unconscious, 
completely  disoriented,  and  perform  all  sorts  of  strange 
acts.  Sometimes  there  develop  transitory  states  of  active 
excitement,  with  noisiness  and  display  of  resistance.  These 
acute  disturbances  usually  disappear  in  the  course  of  a  few 
days  or  weeks,  leaving  as  residuals  the  symptoms  of  the 
original  disease  process,  which  almost  always  is  an  arterio- 
sclerosis or  syphilitic  endarteritis.  The  patients  may 
become  wholly  clear  mentally,  or  may  exhibit  the  various 
symptoms  of  arteriosclerotic  or  syphilitic  insanity,  already 
sufficiently  described.  In  embolism,  the  mental  symptoms 
may  suddenly  and  entirely  disappear.  However,  the  per- 
sistence of  aphasic  or  paraphasic  disturbances  may  make 
it  appear  that  the  patient  exhibits  more  marked  mental 
weakness  than  really  exists. 

Cerebral  Trauma.1  —  Mental  disturbances  accompanying 
head  injury,  widely  designated  as  traumatic  insanity, 
comprise  a  considerable  group  of  cases.  It  has  been  de- 
monstrated that  in  cases  of  severe  trauma  there  exist 
profound  cellular  changes  in  the  cortex,  and  besides  this, 
areas  of  contusion  and  punctate  hemorrhages  at  a  distance 
from  the  point  of  injury,  particularly  on  the  inferior  surface 
of  the  brain,  and  at  the  tips  of  the  frontal  lobes,  in  the 
temporal  and  occipital  lobes. 

Traumatic  insanity  in  the  narrow  sense  comprises 
traumatic  delirium  and  traumatic  dementia  (post  traumatic 
constitution,  Meyer).  Cerebral  trauma  should  also  be 
regarded  as  a  prominent  etiological  factor  in  epilepsy  and 
in  the  traumatic  neuroses.  Insolation  is  regarded  as  a 
form  of  cerebral  trauma. 

1  Meyer,  Am.  Jour,  of  Ins.,  LX,  373  ;  Guder,  Die  Geistesstorungen  nach 
Kopfverletzungen,  1886;  Koppen,  Archiv  f.  Psy.,  XXXIII,  568. 


ORGANIC  DEMENTIAS  345 

Traumatic  delirium  (primary  traumatic  insanity)  de- 
velops following  the  loss  of  consciousness  incident  to  the 
head  injury.  The  patients,  instead  of  becoming  clear, 
present  befogged  states  with  complete  disorientation,  diffi- 
culty of  thought,  and  very  little  or  no  memory  of  the  accident. 
Sometimes  the  amnesia  includes  a  period  just  preceding 
the  accident,  and  not  infrequently  there  is  amnesia  for  other 
isolated  periods  of  the  life  of  the  patients.  They  perceive 
poorly,  and  have  difficulty  in  seeing  the  connection  of  things. 
There  is  often  a  marked  tendency  to  fabrication.  Emotion- 
ally, they  are  irritable  or  indifferent.  They  are  apt  to  be 
restless,  at  times  aggressive,  often  whining  and  talking 
considerably,  the  content  of  the  speech  being  rambling  and 
incoherent.  Delusions  and  hallucinations  are  rarely  pres- 
ent. There  is  no  clear  insight  into  the  disease,  and  the 
patients  speak  of  themselves  as  being  perfectly  well.  This 
state  is  sometimes  accompanied  by  transitory  aphasic 
states.  The  symptoms  of  traumatic  delirium  may  last  for 
many  weeks,  some  cases  persisting  for  several  months, 
after  which  the  patients  usually  recover,  although  sometimes 
the  condition  of  traumatic  dementia  supervenes. 

In  traumatic  dementia  there  develops  sooner  or  later  after 
the  immediate  effects  of  the  injury,  and  in  some  cases 
even  where  there  never  has  been  a  loss  of  consciousness, 
a  change  of  disposition.  This  alteration  may  even  be  so 
indefinite  that  all  the  friends  can  say  is  that  he  is  a  changed 
man.  This  change  usually  consists  of  an  increased  suscepti- 
bility to  fatigue;  i.e.  unusual  fatigue  upon  slight  exertion; 
some  forgetfulness,  confusion  of  thought,  inattention,  un- 
wonted timidity,  occasional  slight  despondency,  with  a  ten- 
dency to  complain  of  many  disagreeable  sensations,  as  dizzi- 
ness, ringing  in  the  ears,  head  pressure,  and  a  certain  sense 
of  heaviness  and  stupidity.    Accompanying  these  complaints 


346  FORMS  OF  MENTAL  DISEASE 

there  is  usually  a  keen  sense  of  illness.  The  patient  is 
irritable,  irascible,  and  at  times  even  exhibits  some  passion. 
Isolated  convulsions  sometimes  develop,  or  even  attacks 
of  petite  mal,  or  temporary  dazed  spells.  Not  only  a  ten- 
dency to  alcoholism,  but  also  a  striking  intolerance  to 
the  influence  of  alcohol  and  other  drugs,  often  appears, 
as  well  as  great  intolerance  to  the  sun's  rays.  The  ca- 
pacity for  employment  is  impaired,  in  explanation  of 
which  the  patient  refers  to  various  subjective  sensations. 
Even  games  and  conversations  are  avoided  for  the  same 
reason. 

The  course  of  the  disease  is  not  distinctly  progressive, 
but  is  sometimes  characterized  by  distinct  exacerbations. 
Many  of  these  exacerbations  can  be  traced  to  alcoholic 
indulgence  or  trivial  emotional  causes.  Deterioration  is 
most  pronounced  where  the  trauma  is  associated  with 
alcoholism  or  arteriosclerosis,  or  where  the  injury  has 
occurred  during  youth.  Usually  there  are  some  nervous 
manifestations  indicative  of  focal  lesions  of  the  brain,  such 
as  changing  pupillary  disorders,  tremors,  paresis  of  facial 
muscles,  and  exaggeration  of  the  tendon  reflexes.  There 
are  a  few  cases  of  traumatic  dementia  which  for  a  time  may 
appear  like  paresis,  but  are  differentiated  from  this  disease 
by  the  changing  character  of  the  pupillary  disturbance 
and  the  characteristic  speech  disorder,  and  the  relatively 
slow  progress  of  the  disease.  Undoubtedly  some  cases  of 
paresis  do  develop  from  brain  trauma  as  a  starting-point. 
This,  however,  is  a  mooted  point,  yet  there  are  many 
observations,  including  those  of  Meyer  and  Koppen, 
which  indicate  its  validity.  Some  of  the  doubtful  cases 
of  traumatic  dementia,  simulating  paresis,  have  presented 
on  post-mortem  examination  an  extensive  arteriosclerosis 
of  the  brain. 


ORGANIC  DEMENTIAS  347 

The  treatment  of  traumatic  insanity  rests  in  early  cases 
with  operative  procedure,  particularly  where  there  is  an 
indication  of  focal  disorder.  In  traumatic  dementia, 
surgical  interference,  even  though  there  may  be  indications 
of  focal  irritation,  is  far  less  successful. 


VIII.     INVOLUTION   PSYCHOSES 

The  forms  of  mental  disease,  described  as  involution 
psychoses  seem  to  bear  some  relationship  to  the  general 
physical  changes  accompanying  involution.  Undoubtedly, 
the  forms  of  mental  disease  included  here  can  occur  in  other 
periods  of  life,  also  there  are  many  other  psychoses  unrelated 
to  involution  that  may  occur  during  the  involution  period; 
as  for  instance,  the  alcoholic  and  infection  psychoses,  manic- 
depressive  insanity,  etc.  The  mental  disturbances  of  the 
early  involutional  period  are  of  a  somewhat  different  stamp 
than  those  characteristic  of  senility,  though  there  are  many 
symptoms  common  to  both.  Those  occurring  in  the  former 
period  are  called  melancholia  and  presenile  delusional  in- 
sanity, and  in  the  latter,  senile  dementia. 

A.  MELANCHOLIA1 

Melancholia  is  restricted  to  certain  conditions  of  mental 
depression  occurring  during  the  period  of  involution.  It 
includes  all  of  the  morbidly  anxious  states  not  represented  in 
other  forms  of  insanity,  and  is  characterized  by  uniform 
despondency  with  fear,  various  delusions  of  self-accusation,  of 
persecution,  and  of  a  hypochondriacal  nature,  with  moderate 

1  v.  Krafft-Ebing,  Die  Melancholie;  Christian,  Etude  sur  la  Melancolie, 
1876;  Voisin,  De  la  Melancolie,  1881;  Dumas,  Les  Etats  Intellectuels 
dans  la  Melancolie,  1895;  Roubinowitsch  et  Toulouse,  La  Melancolie, 
1897.     Hoch,  Rev.  Ed.  of  Reference  Handbook  of  Medicine,  p.  117. 

348 


MELANCHOLIA  349 

clouding  of  consciousness,  leading  in  the  greater  number  of 
cases,  after  a  prolonged  course,  to  moderate  mental  deteriora- 
tion. 

Etiology.  —  The  disease  is  essentially  one  of  the  early 
senile  period,  as  the  majority  of  cases  occur  between  the  ages 
of  fifty  and  sixty.  It  seldom  develops  under  forty  or  over 
sixty.  Sixty  per  cent,  of  the  cases  are  women,  in  whom  the 
disease  tends  to  occur  somewhat  earlier,  apparently  bearing 
some  relation  to  the  climacterium.  Defective  heredity 
occurs  in  only  a  little  over  one-half  of  the  cases,  but  it  is  a 
striking  fact  that  the  parents  and  brothers  and  sisters  of 
melancholiacs  frequently  suffer  from  apoplexy,  senile  de- 
mentia, or  alcoholism.  External  influences,  such  as  mental 
shock,  especially  illness  and  loss  of  friends,  acute  and 
chronic  diseases,  and  surgical  operations,  seem  to  play  a 
rather  important  role  as  exciting  causes  of  the  disease. 

Pathological  Anatomy.  —  In  many  cases  there  is  found 
extensive  arteriosclerosis  and  its  attendant  results  in  the  heart 
and  kidneys.  Sometimes  there  is  evidence  of  beginning  brain 
atrophy.  Alzheimer  found,  in  the  deeper  layers  of  the 
cortex,  in  addition  to  the  changes  in  the  nerve  cells,  an  ex- 
tensive fibril  production  of  the  neuroglia. 

Symptomatology.  —  The  onset  of  the  disease  is  gradual, 
and  is  often  preceded  for  months  and  even  years  by  many 
indefinite  prodromal  symptoms;  such  as,  persistent  headache, 
vertigo,  indefinite  pains,  general  debility,  insomnia,  loss  of 
appetite,  constipation,  palpitation  of  the  heart,  ringing  in  the 
ears,  and  increasing  difficulty  with  work.  The  patients  at 
first  become  sad,  dejected,  and  apprehensive,  and  find  no 
enjoyment  in  their  work  or  home  environment.  They  are 
overshadowed  by  doubts,  fears,  and  self-accusations,  and  can- 
not be  consoled.  They  feel  ill,  complain  of  being  dull, 
confused,  and  forgetful,  and  find  it  difficult  to  do  anything. 


350  FORMS  OF  MENTAL  DISEASE 

During  this  period  there  are  occasional  days  when  they  are 
free  from  fear  and  sorrow. 

Delusions  of  self-accusation  become  prominent.  Some- 
times the  patients  accuse  themselves  only  in  a  general  way: 
they  are  wicked,  are  not  worth  anything,  have  made  fools  of 
themselves,  have  been  impure,  and  are  not  worthy  to  live. 
But  usually  the  self-accusations  refer  to  definite  experiences. 
Patients  become  retrospective,  and  refer  to  many  misdeeds 
in  going  over  the  past  life  which  are  held  as  an  adequate 
basis  for  their  sorrow.  Remote  and  often  insignificant  facts 
are  recalled,  such  as  the  stealing  of  fruit  in  childhood,  dis- 
obedience to  parents  and  neglect  of  friends,  which  now  cause 
them  the  greatest  sorrow  and  anxiety.  Their  whole  life  has 
been  made  up  of  similar  misdeeds.  A  patient  was  miserable 
because  she  had  requested  her  sick  sister  to  remain  out  of  the 
kitchen ;  another,  because  at  the  death  of  her  mother  she  had 
allowed  herself  to  think  of  and  mention  the  division  of 
property.  Many  refer  to  former  sexual  indiscretions.  Some 
patients  reproach  themselves  for  everything;  they  cannot 
do  anything  right.  Everything  in  the  environment  is  a 
source  of  special  anxiety  to  themselves;  the  lamentations  of 
a  fellow-patient  are  directly  the  result  of  their  own  misdeeds. 
Others  want  for  food  if  they  eat.  These  references  vary  from 
day  to  day,  or  may  be  maintained  with  great  firmness  for  a 
long  time.  Quite  often  the  self-accusations  refer  to  religious 
experiences.  The  patients  are  not  as  fervent  in  prayer  as 
formerly;  they  no  longer  possess  real  religious  feeling,  or 
have  sinned  against  the  Holy  Ghost,  are  possessed  by  the 
devil,  etc.  Occasionally  their  self-accusations  center  about 
actual  misdeeds,  which  during  health  long  since  ceased  to 
cause  anxiety. 

In  addition  to  these  self-accusations  the  patients  some- 
times harbor  the  conviction  that  they  themselves  must  be 


MELANCHOLIA  351 

killed  or  that  one  of  their  children  is  to  be  sacrificed.  They, 
furthermore,  are  constantly  finding  "signs"  and  "  meanings" 
which  God  has  intended  for  them.  There  are  often  as- 
sociated with  these  delusions  of  self -accusations  many  other 
depressive  delusional  ideas,  chief  among  which  are  the  fears 
of  punishment.  The  patients  believe  themselves  so  wicked 
that  God  has  forsaken  them  and  they  are  doomed  to  hell, 
they  will  be  turned  out  of  their  home,  brought  to  court, 
thrown  into  prison,  or  killed  outright.  People  are  waiting 
outside  to  carry  them  off,  a  death  warrant  is  already  signed. 
There  is  no  need  of  taking  food;  they  would  rather  starve 
and  suffer  for  their  misconduct,  and  even  ask  to  be  executed. 
Not  infrequently  they  exaggerate  their  misdeeds  and  con- 
fess crimes  which  they  have  never  committed,  in  order  to 
secure  severer  punishment  and  to  relieve  their  guilty  con- 
sciences. 

In  other  cases  the  delusions  are  of  a  more  hypochon- 
driacal nature.  Patients  insist  that  they  are  the  most  un- 
fortunate individuals  in  the  world ;  the  stomach  is  gone,  the 
lungs  are  filled  up,  the  limbs  shrunken,  and  all  sensation 
lost.  The  brain  and  nerves  are  rotting  away  as  the  result  of 
former  sexual  abuse.  They  fear  that  they  are  dying  of  con- 
sumption or  cancer,  and  that  they  are  going  out  of  their  minds 
and  must  end  their  days  in  an  asylum.  They  maintain  that 
the  body  has  been  poisoned,  destroying  all  appetite,  and  now 
they  must  starve.  They  also  express  considerable  fear 
for  themselves  and  families;  they  will  be  deprived  of  their 
home,  some  great  calamity  will  visit  them,  the  children  will 
die,  or  they  themselves  will  be  robbed  and  killed,  will  be 
driven  from  the  church  and  damned  by  God.  These  depres- 
sive delusions  so  thoroughly  influence  their  actions  that  they 
become  seclusive,  eat  sparingly  or  not  at  all,  refuse  to  spend 
money,  and  clothe  themselves  and  their  children  scantily. 


352  FORMS  OF  MENTAL  DISEASE 

They  give  up  everything  because  they  have  only  a  short  time 
to  live. 

Hallucinations  of  hearing  and  sight  often  accompany  this 
condition,  but  they  are  usually  indefinite  and  of  short  dura- 
tion. The  patients  also  refer  to  an  inner  voice  which  com- 
mands them  to  commit  suicide,  or  constantly  repeats  to  them 
that  they  are  wicked  and  guilty.  The  consciousness  is 
usually  clear.  The  patients  are  well  oriented,  with  the 
possible  exception  of  some  delusional  ideas,  in  accordance 
with  which  they  may  claim  that  they  are  in  a  prison,  or  they 
may  mistake  strangers  for  acquaintances  and  insist  that  the 
letters  which  they  receive  are  not  real;  but  in  spite  of  these 
ideas,  it  may  be  readily  seen  that  apprehension  itself  is  not 
much  disordered. 

Thought  is  coherent  and  relevant,  but  the  content  is  usu- 
ally monotonous  and  centered  about  the  depressive  ideas,  to 
which  they  constantly  recur,  recounting  their  various  mis- 
deeds and  fears.  Very  often  they  show  a  tendency  to  repeat 
certain  phrases,  as  "  Let  me  go  home,"  "  Let  me  go  home; " 
"  I  want  to  see  my  children,"  "  I  want  to  see  my  children." 
There  is  usually  some  insight  into  the  change  which  they  have 
undergone  and  they  will  complain  that  their  head  is  not  right, 
but  they  fail  to  recognize  many  symptoms  of  the  disease  as 
such. 

There  is  a  smaller  group  of  cases  of  melancholia  of  involu- 
tion occurring  somewhat  later  in  life,  in  which  the  various 
delusions  of  self-accusation,  of  fear,  misfortune,  and  persecu- 
tion are  much  more  fantastic  and  senseless.  In  these  cases 
the  entire  environment  appears  to  the  patients  to  be  changed. 
Their  home  is  transformed  into  a  dungeon,  into  a  house  of  ill 
repute,  or  a  deserted  prison  from  which  there  are  no  means  of 
escape.  Things  about  them  seem  unnatural  and  have  a 
gloomy  aspect;  passing  carriages  are  regarded  as  a  funeral 


MELANCHOLIA  353 

procession ;  the  tolling  of  the  church  bell  indicates  that  some 
one  has  died.  A  spoon  lying  on  the  table  means  that  medi- 
cine has  been  taken  by  some  one  who  is  now  at  the  point  of 
death.  Hammer  and  nails  found  on  the  floor  signify  that  a 
scaffold  is  being  secretly  built  for  their  execution.  Chance 
remarks  have  a  hidden  meaning.  Their  food  is  the  flesh  and 
blood  of  their  relatives.  Everything  is  awfully  changed  for 
them;  friends  and  relatives  are  not  real;  the  sun  and  the 
moon  look  different;  the  end  of  the  world  has  come;  and  they 
are  now  to  be  passed  into  a  lion's  den.  The  patients  accuse 
themselves  of  horrible  crimes,  for  which  they  are  exiled  or 
must  die  on  the  gallows;  have  murdered  their  husbands, 
devoured  their  children,  or  have  brought  sin  upon  the  whole 
world.  All  wickedness  is  due  to  them ;  they  have  desecrated 
the  communion  bread,  or  have  spat  upon  the  image  of  Christ. 
They  are  totally  unworthy,  should  be  buried  alive,  no  one 
should  speak  to  them,  hanging  is  too  good,  and  they  should 
be  thrown  into  molten  metal. 

In  some  cases  the  so-called  "  nihilistic  delusions"  (delire 
de  negation)  predominate,  when  the  patients  claim  that 
nothing  exists,  there  is  no  more  food,  no  more  houses,  no 
more  trees,  no  cities,  no  day  or  night,  no  sun  or  moon,  no 
living  being.  They  are  alone  in  the  universe,  as  there  is  no 
world.  They  themselves  have  no  name,  no  wife,  no  children. 
They  cannot  eat,  cannot  speak,  cannot  die.  Their  body  is  all 
shrunken  up,  their  bowels  never  move,  and  food  has  been 
accumulating  in  them  for  months.  They  no  longer  possess 
a  heart  or  lungs;  they  cannot  breathe  or  even  walk. 

Extremely  absurd  hypochondriacal  ideas  are  apt  to  be 
expressed.  The  patients  claim  that  they  have  no  breath,  the 
blood  has  stopped  circulating,  the  veins  have  dried  up,  the 
eyes  are  rotting  away,  maggots  are  crawling  under  the  skin, 
their  brain  is  solid  rock,  their  limbs  are  transformed  to  hoofs 

2a 


354  FORMS  OF  MENTAL  DISEASE 

and  the  face  to  that  of  a  wild  animal.  Occasionally  sexual 
delusions  of  a  silly  character  are  present,  the  patients  main- 
taining that  they  have  been  outraged  at  night,  are  now  in  a 
house  of  ill  repute,  or  surrounded  by  men  disguised  as 
women.  These  depressive  delusions  are  definite,  coherent, 
and  usually  well-retained.  There  are  a  few  cases,  especially 
those  with  progressive  mental  deterioration,  in  which  a  few 
expansive  delusions  appear. 

Hallucinations,  especially  of  hearing,  and  also  of  sight  are 
prominent.  Voices  and  bells  are  heard,  the  devil  commands 
them,  strangers  insult  them,  and  they  hear  the  evil  thoughts 
of  others.  They  see  strange  forms  beside  them  at  night, 
moving  bodies  and  spirits.  Occasionally  they  detect  strange 
odors  and  tastes  in  food,  and  smell  vapors  at  night. 

Consciousness  in  these  cases  is  usually  clouded  and  there 
is  some  disorientation  for  time,  place,  and  persons.  The 
train  of  thought  is  somewhat  confused  and  monotonous,  with  a 
tendency  to  repeat  compulsively  such  phrases  as,  '^Yhat  did 
I  do  ?"  "  What  did  I  do  ?"  "My  God  !  my  God  !"  Yet 
it  is  sometimes  surprising  to  find  how  well  patients  answer 
questions  and  describe  their  symptoms.  Sometimes  the 
patients  are  partially  conscious  of  the  nature  of  their  illness 
and  complain  that  they  have  been  made  foolish  and  crazy  by 
poison  placed  in  their  food  or  hypnotic  influence.  In  other 
cases  the  patients  are  wholly  unable  to  recognize  the  contra- 
dictions in  their  absurd  statements :  at  one  minute  they  will 
claim  that  they  have  been  destroyed  by  poison,  and  at  the 
next  that  they  cannot  die. 

The  emotional  attitude  is  uniformly  one  of  depression.  The 
basis  for  this  emotional  depression  seems  to  be  fear,  a  feeling 
of  oppression,  an  inner  anxiety.  Some  patients  claim  that 
it  is  as  if  a  heavy  weight  were  upon  the  chest.  They  are 
timid,  uneasy,  and  feel  as  though  homesick.    The  fear  is 


MELANCHOLIA  355 

increased  by  association  with  those  who  are  accustomed 
to  arouse  in  them  the  deepest  feelings,  while  strangers  and 
new  environment  create  little  emotional  reaction.  Emo- 
tional outbreaks  may  be  present  at  times,  when  the  patients 
are  greatly  agitated,  and  may  even  present  a  dreamy  dis- 
turbance of  consciousness.  These  frequently  follow  visits  of 
relatives  or  some  unusual  occurrence. 

In  conduct,  the  patients  no  longer  feel  the  impulse  to  work; 
work  is  hard  to  finish.  Yet  they  cannot  remain  quiet,  they 
cannot  remain  in  bed,  and  wander  about  the  house  in  an 
aimless  manner.  They  complain,  lament,  and  pray;  visit 
physicians  and  the  clergy  in  order  to  receive  sympathy, 
although  they  know  that  no  one  can  help  them.  Many 
patients  develop  a  feverish  activity,  they  beg  piteously  for 
work,  they  work  at  night  and  struggle  along  until 
completely  exhausted  in  order  to  take  their  minds  off 
their  sorrow  and  fear. 

The  countenances  of  the  patients  give  clear  evidence  of 
their  anxiety.  Occasionally  in  very  severe  cases  there  may 
appear  transiently  a  peculiar  indefinite  laughter,  which  by 
no  means  represents  an  elated  emotional  state,  but  is  rather 
an  expression  of  desperate  irony.  They  feel  compelled  to 
talk  about  their  condition.  They  always  have  something  to 
communicate  to  the  doctor,  but  one  finds  that  it  is  always  the 
same  old  story.  It  is  a  striking  peculiarity  that  these  patients 
become  quiet  when  transferred  to  a  new  environment. 
They  become  natural  in  their  manner,  are  approachable,  and 
are  able  to  conceal  their  anxiety.  They  claim  that  everything 
will  be  all  right  again  if  they  could  only  return  home  and  to 
work,  but  careful  observation  shows  the  real  depth  of  their 
emotional  excitement.  After  the  disease  has  been  in  exist- 
ence some  time,  the  patients  may  be  able  to  remain  quiet  and 
more  or  less  indifferent  for  a  much  longer  time.    But  as  soon 


356  FORMS  OF  MENTAL  DISEASE 

as  one  comes  into  close  companionship  with  them,  he  will 
observe  occasional  evidences  of  emotional  outbursts. 

Commands  are  carried  out  without  delay,  unless  they 
create  some  anxiety.  The  individual  movements  are  usually 
free  and  unrestrained,  although  they  are  usually  performed 
without  any  special  strength  or  rapidity,  especially  in  patients 
much  reduced  physically.  There  is  no  striking  disorder  in 
writing. 

The  patients  eat  irregularly  and  many  even  refuse  food 
altogether,  sometimes  because  they  wish  to  die,  at  others 
because  they  are  not  worthy  of  food.  Others  suspect  poison 
or  excrement  in  their  food.  Similarly,  patients  refuse  to 
take  medicines  and  to  bathe  themselves.  Some  patients  are 
untidy  and  even  soil  themselves. 

The  tendency  to  commit  suicide  is  more  pronounced  and 
more  to  be  guarded  against  in  melancholia  than  in  any  other 
form  of  mental  disease.  The  desire  to  end  life  may  be  the 
outcome  of  deliberation,  or  because  they  are  repudiated  by 
God.  But  usually  the  thoughts  of  death  arise  suddenly  and 
are  impulsive.  Not  infrequently  they  suddenly  develop 
during  convalescence.  Often  their  attempts  at  suicide  are 
not  remembered.  Sometimes  the  suicidal  attempts  are  among 
the  first  symptoms  of  the  disease.  Every  melancholiac  should, 
therefore,  be  regarded  as  a  dangerous  patient,  and  the  more 
so,  the  more  conscious  he  is  and  the  more  capable  of  conceal- 
ing his  anxiety.  Determined  to  commit  suicide,  these 
patients  resort  to  all  sorts  of  devices  to  accomplish  their 
purpose.  Some  attempt  to  drown  themselves  in  the  bath- 
tub, others  ram  their  heads  against  the  wall ;  many  hang  or 
attempt  to  strangle  themselves  by  tying  something  about 
their  necks.  In  their  agitation  they  seem  to  be  quite  in- 
sensible to  pain.  One  of  my  patients  reduced  her  scalp  to 
pulp  with  a  hammer,  fracturing  her  skull  in  several  places. 


MELANCHOLIA  357 

Other  patients  swallow  glass,  nails,  ink,  or  in  fact  anything 
that  they  can  secure. 

In  case  the  anxiety  is  accompanied  by  greater  excitement, 
the  patients  cannot  remain  quiet,  but  pace  back  and  forth, 
wringing  their  hands,  pulling  at  their  hair,  moaning  and 
lamenting  until  so  hoarse  that  they  can  barely  speak  aloud. 
In  their  great  anguish  they  persistently  pick  at  their  nose, 
face,  or  fingers  until  smeared  with  blood,  pull  out  their 
hair,  tear  their  clothing,  and  pound  themselves.  Kraepelin 
questions  whether  this  extreme  picture  really  belongs  to 
melancholia  or  should  be  classified  in  a  group  as  yet  un- 
differentiated. These  cases,  anatomically,  usually  present 
severe  and  extensive  lesions  in  the  cortex  in  which  there 
is  destruction  of  very  many  nerve  cells. 

Physical  Symptoms.  —  Insomnia  is  an  early  and  promi- 
nent symptom.  The  sleep  is  scanty,  much  disturbed  by 
dreams,  and  unrefreshing.  Occasionally  there  are  observed 
the  early  signs  of  the  senile  changes;  such  as  attacks  of 
dizziness,  sluggish  pupillary  reaction,  paresis  of  the  facial 
muscles,  and  tremor  of  the  tongue  and  hands.  The  patients 
also  complain  of  uncomfortable  sensations  about  the  heart; 
a  sort  of  tension,  a  pressure,  or  an  "  anxious  feeling,"  which 
is  regularly  worse  at  night.  The  muscular  power  is  dimin- 
ished and  there  is  some  general  physical  weakness.  The 
nutrition  suffers  and  the  weight  falls.  Appetite  is  poor  or 
completely  lacking,  the  bowels  are  very  sluggish,  the  tongue 
coated,  and  the  breath  foul.  The  mucous  surfaces  are 
anaemic.  The  temperature  frequently  remains  below  normal. 
Circulatory  disturbances  are  often  present;  as,  cyanosis, 
coldness  and  edema  of  the  limbs.  The  pulse  may  be 
small  and  irregular  or  slow,  and  the  arteries  may  give 
evidence  of  beginning  sclerosis.  Other  changes,  indica- 
tive of  senility,  are  sluggish  reaction  of  pupils,  grayness  of 


358  FORMS  OF  MENTAL  DISEASE 

the  hair,  cessation  of  the  menses,  dryness  and  harshness 
of  the  skin. 

Course.  —  There  is  a  gradual  development,  a  prolonged 
duration,  and  a  still  more  gradual  convalescence.  In  cases 
of  recovery  the  whole  course  lasts  at  least  twelve  months  to 
two  years.  Short  remissions,  during  which  there  is  only  a 
partial  disappearance  of  the  symptoms,  are  characteristic  of 
the  entire  course.  There  is  often  present  a  daily  improve- 
ment toward  evening,  and  an  exacerbation  of  the  symptoms 
during  the  morning.  Exacerbations  often  arise  as  the  result 
of  annoyance,  fatigue,  and  excitation,  such  as  that  induced  by 
visits.  A  gradual  improvement  of  the  sleep  and  nutrition, 
especially  an  increase  in  weight,  may  be  regarded  as  a  favor- 
able sign.  The  remissions  become  longer  and  more  marked, 
and  the  anxiety  gives  way  to  irritability  and  fretfulness;  the 
patients  then  begin  to  display  interest  in  work  and  reading. 
Even  when  convalescence  is  well  established,  it  is  not  un- 
usual for  them  to  have  "  bad  days,"  during  which  they  are 
troubled  and  fearful. 

Diagnosis.  —  The  distinguishing  characteristics  of  melan- 
cholia of  involution  are  a  slow  development,  uniform 
course,  long  duration,  gradual  improvement,  and  doubtful 
prognosis.  These  characteristics  only  partially  suffice  for 
the  differentiation  of  melancholia  from  the  depressive 
phase  of  manic-depressive  insanity.  In  addition,  the  dis- 
quietude of  the  melancholiac  is  contrasted  with  the  more 
dejected  and  hopeless  attitude  of  the  manic-depressive 
patient.  This  difference  is  especially  well  marked  in  the 
early  stages  of  the  disease,  when  the  melancholiac  shows 
more  clearly  anxiety  and  restlessness  and  the  manic-depres- 
sive patient  a  dismal  despondency  and  sadness.  In  melan- 
cholia the  emotional  attitude  is  much  more  uniform. 
Although  the  melancholiac  may  show  some  variation  in  the 


MELANCHOLIA  359 

intensity  of  his  feelings,  the  anxiety  is  always  present,  and  it 
is  not  possible,  as  it  sometimes  is  in  manic-depressive  in- 
sanity, by  consoling  or  joking  with  them,  to  make  them  cheer- 
ful and  smiling.  Furthermore,  in  the  psychomotor  field  we  do 
not  observe  the  retardation,  which  is  usually  so  pronounced 
in  manic-depressive  insanity.  The  patients  have  no  diffi- 
culty in  expressing  themselves  orally  or  by  writing ;  they  are 
unhampered  in  their  movements  and  actions.  If  they  hap- 
pen to  be  silent  and  refuse  to  speak,  it  is  evident  that  this 
arises  from  their  desperation  or  their  delusions.  They  are 
usually  communicative  and  talkative  enough  whenever  they 
can  secure  consolation. 

The  differentiation  is  by  no  means  as  easy  in  some  of  the 
mixed  phrases  of  manic-depressive  insanity,  in  which  the  de- 
spondency is  associated  with  some  excitement  and  not  with 
retardation.  In  such  cases  the  distinction  depends  upon  the 
fact  that  the  emotional  state  in  the  mixed  phases  is  usually 
less  anxious  than  irritable,  is  accompanied  by  grumbling  and 
at  times  faint-heartedness,  that  restless  patients  can  be 
easily  influenced  by  conversation  to  become  quiet  and  even 
cheerful,  and  finally,  that  the  excitement  is  not  an  expression 
of  the  feelings,  but  an  independent  disturbance  which  stands 
in  no  relation  to  the  intensity  of  the  feelings. 

The  depression  of  catatonia  developing  during  involution 
is  distinguished  from  melancholy  by  the  presence  and  persist- 
ence of  hallucinations  and  the  inaccessibility  of  the  patients. 
The  melancholiac  is  resistive  and  inaccessible  only  in  con- 
nection with  his  anxiety  or  his  delusions.  He  is  usually 
influenced  by  conversation,  and  participates  in  the  conversa- 
tion when  visited  by  friends,  while  the  catatonic  shows 
emotional  indifference,  negativism,  and  constrained  and 
manneristic  conduct.  The  uniform  lamentation  and  wring- 
ing of  the  hands  in  melancholia  contrasts  with  the  senseless 
stereotypy  of  the  catatonic. 


360  FORMS  OF  MENTAL  DISEASE 

Symptoms  characteristic  of  senile  dementia  sometimes 
develop  in  melancholia,  rendering  the  prognosis  less  favor- 
able. Such  symptoms  are,  chiefly,  the  interference  with  the 
impressibility  of  memory,  the  tendency  to  fabrications,  loss 
of  orientation,  emotional  indifference,  silly  obstinacy,  and 
nocturnal  restlessness.  The  fantastic  and  nihilistic  character 
of  delusions  is  not  an  unfavorable  sign,  but  senile  physical 
changes  are;  namely,  decrepitude,  atrophic  changes  in  the 
skin,  bones,  and  muscles,  and  the  evidences  of  arteriosclerosis 
in  the  heart  and  vessels. 

Melancholia  has  no  connection  with  the  arteriosclerotic 
brain  lesions.  The  depressed  states  occurring  in  arterioscle- 
rotic insanity  are  distinctly  hypochondriacal  and  accompanied 
by  evidences  of  dementia  and  of  severe  brain  lesions. 

Considerable  trouble  may  be  experienced  in  differentiating 
the  depressed  form  of  dementia  paralytica.  In  melancholia 
one  finds  a  subacute  onset  following  definite  prodromal 
symptoms,  greater  or  less  clouding  of  consciousness,  a  more 
consistent  emotional  attitude,  and  absence  of  evidences  of 
mental  deterioration  early  in  the  disease,  while  in  dementia 
paralytica  there  is  a  gradual  onset  with  early  evidence  of 
mental  deterioration,  defective  time  orientation,  poor  judg- 
ment and  memory,  silly  and  contradictory  delusions. 
Furthermore,  the  emotional  attitude  does  not  always  cor- 
respond with  the  ideas  expressed,  and  consciousness  is  more 
deeply  clouded. 

Prognosis.  —  The  prognosis  is  not  favorable,  considering 
that  only  one-third  of  the  cases  fully  recover.  Twenty- 
three  per  cent,  of  the  cases  improve  so  as  to  be  able  to  return 
home  and  live  comfortably,  sometimes  aiding  in  the  main- 
tenance of  the  family,  twenty-six  per  cent,  become  de- 
mented, and  nineteen  per  cent,  die  within  two  or  three  years. 
The  patients,  being  apathetic  and  anergetic,  and  taking  little 


MELANCHOLIA  361 

exercise  and  insufficient  food,  become  more  and  more  emaci- 
ated, and  finally  succumb  to  cardiac  weakness  or  some  infec- 
tious or  chronic  disease.  The  prognosis  is  less  favorable  in 
cases  occurring  after  fifty-five  years  of  age. 

In  those  cases  that  improve,  but  do  not  recover,  the  depres- 
sion and  the  delusions  gradually  disappear,  and  the  con- 
sciousness becomes  perfectly  clear,  but  the  patients  fail  to 
develop  full  interest  in  the  surroundings  and  to  adapt  them- 
selves to  any  kind  of  work.  They  are  dull,  sluggish,  and 
indifferent,  and  tend  to  be  low  spirited  and  tearful.  In  those 
that  become  more  demented  the  delusions  fade  very  gradu- 
ally, but  the  patients  fail  to  gain  insight  and  show  poverty  of 
thought.  They  are  forgetful,  apathetic,  and  entirely  unable 
to  apply  themselves.  They  stand  around  stupidly  or  lament 
in  a  monotonous  fashion.  Others  develop  the  typical 
picture  of  senile  dementia.  Residuals  of  former  delusions, 
as  well  as  a  few  hallucinations  and  some  expansive  ideas, 
remain. 

Treatment.  —  The  chief  essential  is  the  establishment  of  a 
"  rest  cure,"  which,  first  of  all,  demands  the  removal  of  the 
patients  from  all  deleterious  influences,  including  the 
nearest  relatives,  the  home  environment,  and  the  customary 
occupation.  Hence  it  is  usually  necessary  to  send  the 
patient  to  a  sanitarium  or  hospital.  This  is  particularly 
urgent  if  suicidal  tendencies  develop. 

It  is  necessary  in  most  cases  that  the  patients  be  confined 
in  bed  with  short  intermissions,  with  sufficient  and  constant 
attendance.  If  the  patient  can  be  confined  in  bed  out  of 
doors  in  a  secluded,  partially  sheltered,  and  sunny  place, 
it  will  be  found  decidedly  beneficial.  It  aids  in  alleviating 
insomnia  and  affords  a  more  interesting  and  attractive 
environment.  In  very  light  cases  a  suitable  change  may  be 
found  in  removal  to  a  different  boarding-place  or  into  the 


362  FORMS  OF  MENTAL  DISEASE 

associations  of  a  happy  family.  It  is  decidedly  not  advisable 
to  attempt  such  distractions  as  might  be  afforded  by  long 
journeys,  sight-seeing,  and  constant  company.  The  rest  in 
bed  should  not  be  too  prolonged;  later  it  is  best  that  it  be 
gradually  replaced  by  short  drives  or  walks,  combined  with 
daily  change  of  scenery. 

Of  next  importance  is  nutrition.  The  food  should  be 
nutritious,  given  in  small  quantities  and  at  frequent  intervals. 
Monotony  in  diet  should  always  be  avoided  by  consulting  the 
tastes  of  the  patient.  Careful  regulation  of  the  intestines, 
combined,  if  necessary,  with  rectal  injections,  usually  im- 
proves the  appetite.  Extreme  anxiety  and  restlessness  often 
necessitate  artificial  feeding  by  stomach  or  nasal  tube  in 
order  to  maintain  nutrition.  When  this  is  contraindicated  by 
cardiac  weakness,  it  is  necessary  to  resort  to  saline  infusions. 

Insomnia,  which  is  both  troublesome  and  often  difficult 
to  overcome,  is  best  combated  at  first  by  prolonged  warm 
baths  in  the  early  evening,  warm  packs,  or  gentle  massage 
provided  it  does  not  increase  the  agitation.  Hot  malted 
milk  before  retiring  may  aid  in  inducing  sleep.  These 
measures,  well  carried  out,  often  render  hypnotics  unneces- 
sary, the  use  of  which  is  always  inadvisable  because  of  the 
prolonged  course  of  the  disease.  Of  the  hypnotics,  alcohol 
is  the  most  useful.  Paraldehyde,  one-half  to  one  fluid 
plram,  trional  in  ten  to  fifteen  grain  doses,  veronal  seven 
and  one-half  grains,  and  somnos  are  the  most  useful. 

The  distressing  condition  of  anxious  restlessness  may  be 
combated  with  opium.  It  is  best  given  in  rapidly  increasing 
doses  beginning  with  five  drops  and  reaching  thirty  to  fifty 
drops  of  the  tincture  of  opium  three  times  daily,  which  is 
gradually  reduced  as  soon  as  the  restlessness  begins  to  sub- 
side. This  drug  sometimes  not  only  fails,  but  serves  to  ag- 
gravate the  symptoms,  when  it  must  be  withdrawn  gradually. 


MELANCHOLIA  363 

Improvement  from  this  source,  if  it  is  to  occur,  appears  within 
a  few  days.  Suicidal  tendencies  necessitate  painstaking, 
careful,  and  constant  watching,  as  melancholiacs  are  the  most 
difficult  to  thwart  in  their  attempts  at  suicide.  This  care 
must  be  as  strenuously  observed  until  recovery  is  well  es- 
tablished. 

The  psychical  influence  which  may  be  constantly  exerted 
over  the  patients  by  those  in  attendance  is  of  the  greatest 
value  in  alleviating  distress,  modifying  the  delusions,  and 
relieving  the  anxiety.  For  this  reason  the  manner  should  be 
gentle,  friendly,  and  assuring,  and  some  attempts  should 
always  be  made  to  lead  the  thoughts  of  the  patients  away  from 
their  depressive  ideas.  As  the  patients  improve  there  should 
be  a  systematic  effort  to  gradually  engage  them  in  some 
light  employment  as  sewing,  reading,  writing,  etc.  Visits 
from  relatives  are  always  deleterious  and  in  the  height  of  the 
disease  must  be  forbidden  Finally,  it  is  of  the  utmost  im- 
portance that  the  patients  be  kept  under  observation  and 
treatment  until  thoroughly  recovered.  A  safe  index  of  this 
may  be  found  in  their  insight  into  the  disease  and  the 
return  of  normal  sleep  and  nutrition. 


B.   PRESENILE   DELUSIONAL   INSANITY 

There  is  a  small  group  of  cases  appearing  during  involu- 
tion which  are  unlike  either  melancholia  or  senile  dementia, 
showing  many  of  the  characteristics  of  dementia  praecox.  It 
has  been  tentatively  differentiated  and  characterized  by  the 
gradual  development  of  marked  impairment  of  judgment, 
accompanied  by  numerous  unsystematized  delusions  of  sus- 
picion and  greatly  increased  emotional  irritability. 

Etiology.  —  The  psychosis  is  rare,  occurring  only  twelve 
times  in  ten  years'  experience.  The  majority  of  the  cases 
are  women,  in  whom  the  disease  appears  between  fifty-five 
to  sixty-five  years  of  age;  while  in  men  it  occurs  about  the 
fiftieth  year.  There  seems  to  be  marked  hereditary  pre- 
disposition to  the  disease. 

Symptomatology.  —  The  onset  of  the  disease  is  gradual, 
with  a  change  of  disposition.  The  patients  at  first  become 
quiet,  seclusive,  discontented,  moody,  suspicious,  and  ir- 
ritable. Then  delusions  gradually  develop  which  at  first  are 
vague  and  transitory,  but  later  become  more  permanent  and 
definite.  Among  the  first  to  appear  are  the  hypochon- 
driacal delusions.  The  patients  complain  of  the  most  varied 
and  changeable  nervous  sensations  and  pains,  spasmodic 
twitchings,  vertigo,  troubled  dreams,  debility,  malaise, 
roaring  in  the  ear,  etc.,  which  remind  one  of  hysterical 
complaints.  These  ideas  later  usually  become  somewhat 
senseless,  and  the  patients  complain  that  the  spine  is  dried 
up,  the  brain  shrunken,  all  strength  has  departed,  etc. 

364 


PRESENILE  DELUSIONAL  INSANITY  365 

Meanwhile,  fantastic  delusions  of  suspicion  appear.  The 
patients  claim  that  their  clothing  has  been  exchanged  or 
stolen;  that  articles  of  furniture  have  been  removed  and 
others  of  less  value  substituted;  thieves  are  about.  They 
suspect  poison  in  the  food;  accuse  the  physician  of  trying 
to  get  rid  of  them,  of  being  obscene,  of  removing  the  womb, 
or  making  them  ill  for  the  purpose  of  studying  their  case. 
The  husband  believes  that  the  wife  is  secretly  dosing  him. 

Delusions  of  infidelity  are  usually  very  numerous  and 
prominent.  The  husband  is  accused  of  eying  women  on  the 
street,  of  flirting  with  every  one  he  meets,  of  caressing  the 
servant,  and  receiving  letters  from  the  schoolmates  of  his 
daughter.  He  arranges  to  meet  women  whenever  he  leaves 
home,  and  has  intercourse  with  every  one  possible.  The 
husband  is  suspicious  of  his  wife  because  she  leaves  him  at 
night,  or  is  surprised  when  he  returns  home  unexpectedly. 

It  is  characteristic  of  all  these  delusions  that  they  are 
exceedingly  unstable.  They  appear  at  one  moment,  are 
abandoned  in  the  next,  and  again  recur  in  another  form.  As 
regards  insight,  many  patients  admit  that  they  might  have 
been  mistaken  and  that  they  are  sick,  but  they  fail  to  really 
appreciate  the  senselessness  of  their  ideas.  Half  an  hour 
later  you  may  find  them  in  the  greatest  distress,  because  they 
have  been  poisoned,  or  because  some  one  has  hidden  under 
the  bed ;  they  are  going  to  die,  etc.  A  soothing  word  usually 
suffices  to  quiet  them  and  dispel  their  fear. 

Hallucinations  accompany  the  delusions  in  only  a  few 
cases.  The  patients  are  sometimes  threatened,  or  hear 
strangers  boast  of  intercourse  with  their  wives.  The  cries 
of  their  ill-treated  children  reach  them.  At  night  they  may 
see  dark  forms  stealing  out  of  the  room,  or  feel  some  one  lying 
beside  their  wives.  It  is  a  noteworthy  fact  that  the  patients 
do  not  make  a  genuine  attempt  to  intercept  these  guilty 


366  FORMS  OF  MENTAL  DISEASE 

parties.  If  a  search  is  instituted  and  they  fail  to  find  any 
one,  they  express  anger  only  because  connubial  fidelity  was 
violated  with  such  shamelessness  and  slyness  in  their  own 
presence. 

Consciousness  is  unclouded  and  orientation  unimpaired. 
Thought  is  coherent,  but  judgment  shows  a  marked  weakness, 
noted  in  the  retention  of  the  most  fantastic  delusions,  while 
the  consciousness  of  the  patient  is  perfectly  clear.  The 
patients  cannot  see  the  senselessness  of  the  delusions,  and 
while  they  may  claim  that  they  are  open  to  conviction,  they 
can  never  be  convinced.  Their  memory  for  remote  events  is 
unimpaired.  However,  in  the  narration  of  their  delusions, 
they  add  all  sorts  of  embellishments  and  misrepresentations. 

The  emotional  attitude  at  first  is  one  of  depression  and  fear; 
occasionally  it  leads  to  suicidal  attempts.  Later  there 
usually  appear  some  excitement  and  irritability.  The  pa- 
tients then  talk  a  good  deal,  make  verbose  complaints,  stir 
up  boisterous  scenes,  fly  into  violent  passion,  and  are  abusive, 
but  they  are  usually  quieted  without  difficulty.  They 
sometimes  laugh  and  cry  without  cause. 

The  conduct  is  characterized  by  all  sorts  of  senseless 
actions.  In  accord  with  their  delusions  many  patients  run 
about  from  one  physician  to  another,  and  solicit  much 
advice  without  attempting  to  follow  any  of  it.  Some  stop 
eating,  seclude  themselves,  destroy  everything  within  reach, 
and  become  violent.  Jealousy  leads  to  strict  surveillance  of 
the  husband  or  wife.  The  servant  is  sent  out  in  search  of 
them;  torn  letters  in  the  waste  basket  are  placed  together  in 
order  to  obtain  proof  of  guilt,  and  the  supposed  seducers  may 
be  publicly  accused. 

With  the  advance  of  the  disease  the  delusions  become  more 
senseless;  the  patients  claim  that  the  wife  and  children  are 
being  tortured,  the  son  nailed  to  the  floor,  or  suspended  on  a 


PRESENILE  DELUSIONAL  INSANITY  367 

fence;  the  wife  wanders  nightly  from  place  to  place,  and 
every  one  is  talking  about  it.  Female  patients  believe  that 
their  husbands  have  intercourse  with  their  own  children,  and 
even  with  other  men,  disguised  as  women.  They  are  aware 
of  this  only  through  sensations  in  their  own  bodies,  when- 
ever they  are  deceived.  The  precious  Lord  proclaims 
everything,  talks  to  them,  and  lies  beside  them  at  night  like  a 
shadow.  Persons  and  the  environment  are  changed;  their 
bodies  are  disfigured  and  influenced.  For  this  reason,  many 
patients  remain  in  seclusion,  veil  themselves,  and  at  times 
refuse  to  speak  and  then  suddenly  become  very  friendly  and 
communicative.  These  delusions  frequently  change,  and 
may  temporarily  fade  away,  although  some  general  signs  of 
them  are  constantly  recurring.  In  spite  of  progressing 
mental  deterioration,  the  patients  do  not  become  incoherent. 
Diagnosis.  —  Some  regard  these  cases  as  paranoia,  but  they 
certainly  differ  from  paranoia,  in  that  the  delusions  are  not 
systematized.  The  persecutors  remain  indefinite  or  change 
frequently,  the  suspected  consorts  are  not  regarded  as 
enemies,  but  are  often  thought  to  have  been  seduced.  More- 
over, the  patients  do  not  find  in  their  delusions  any  broad 
basis  for  action,  and  except  for  their  occasional  violent  out- 
breaks, do  not  treat  the  supposed  persecutor  as  especially 
hostile;  they  associate  with  their  faithless  wives,  in  fact 
even  force  themselves  into  their  company,  and  surprise  one 
by  becoming  friendly  toward  those  persons  whom  they  have 
just  previously  suspected  and  accused.  They  often  prefer  to 
be  confined  in  the  hospital  in  spite  of  complaining  of  all  sorts 
of  persecution,  because  they  enjoy  the  protection  afforded 
them  there.  Finally,  the  delusions  do  not  continue  stable, 
but  change  frequently,  and  sometimes  even  in  a  short  time. 
The  conditions  of  excitement  seem  to  depend  less  upon 
deliberation  than  emotional  vacillations. 


368  FORMS  OF  MENTAL  DISEASE 

Some  consider  these  cases  of  dementia  prcecox,  which  may 
occur  at  this  age,  although  not  frequently.  These  patients 
do  not  present  catatonic  symptoms.  The  peculiar  resistive- 
ness  and  excitement  occasionally  manifested  are  not  com- 
pulsive or  spontaneous,  but  depend  upon  delusions  or 
moods.  The  patients  do  not  become  apathetic  rapidly,  but, 
on  the  contrary,  continue  irritable  and  interested,  while 
disturbances  of  judgment  greatly  predominate  over  those  of 
the  emotions  and  actions. 

Prognosis.  —  The  outcome  is  never  characterized  by 
profound  dementia  or  confusion  of  speech,  but  by  a  moderate 
deterioration,  with  isolated,  changeable,  and  incoherent 
delusions.  Recoveries  or  marked  improvements  are  not 
likely  to  occur. 

Treatment.  —  The  treatment  is  wholly  symptomatic. 
Most  patients  are  troublesome  and  need  hospital  treatment, 
but  some,  under  favorable  conditions,  are  able  to  remain  at 
home. 


C.    SENILE  DEMENTIA1 

Senile  dementia  is  characterized  by  a  gradually  progres- 
sive mental  deterioration,  occurring  during  the  period  of  in- 
volution and  accompanied  by  a  series  of  lesions  in  the  central 
nervous  system.  It  comprises  several  groups  of  cases,  in- 
cluding simple  senile  deterioration  of  lighter  and  severer 
grades,  presbyophrenia,  senile  delirium,  and  senile  delu- 
sional insanity. 

Etiology.  —  The  disease  may  appear  at  any  time  during 
involution,  but  is  encountered  most  frequently  between 
sixty  and  seventy-five  years  of  age.  Individuals  with  a 
faulty  constitutional  endowment,  worn  with  hardships,  and 
especially  those  addicted  to  excesses,  may  succumb  before 
sixty.  Men  who  have  been  more  exposed  to  overwork  and 
excesses  develop  the  disease  earlier  than  women.  Defec- 
tive heredity  occurs  in  about  fifty  per  cent,  of  cases,  but  is 
confined  mostly  to  senile  deterioration  in  parents  and  in 
brothers  and  sisters.  Very  frequently  the  disease  develops 
immediately  following  an  injury,  particularly  head  injury, 
emotional  shocks,  also  acute  febrile  diseases,  especially 
influenza  and  bronchitis. 

1  Fuerstner,  Archiv  f .  Psychiatrie,  XX,  2 ;  Noetzli,  Uber  Dementia 
Senilis,  Diss.  Zuerich,  1895;  Alzheimer,  Monatsschrift  f.  Psychiatrie  u. 
Neurologie,  1898,  101;  Scholoess,  Wiener  Klinik,  XXV,  9  u.  10,  1899; 
Colella,  Annali  di  Neurologia,  1899,  6;  Zingerle,  Jahrb.  f.  Psychiatrie, 
XVIII,  256.  Pickett,  The  Jour,  of  Nervous  and  Mental  Disease,  1904, 
p.  81. 

2  b  369 


370  FORMS  OF  MENTAL  DISEASE 

Pathological  Anatomy.  —  All  advanced  cases  of  senile 
dementia  present,  both  macroscopically  and  microscopically, 
atrophy  of  the  nerve  substance.  The  brain  weight  is  from 
two  hundred  to  five  hundred  grams  below  normal.  There 
may  be  compensatory  thickening  of  the  cranium,  and  in- 
crease of  the  cerebrospinal  fluid  (hydrocephalus  ex-vacuo). 
The  dura  is  usually  adherent  to  the  calvarium.  The  Pac- 
chionian granulations  are  increased  in  size.  Pachymen- 
ingitis interna  hemorrhagica  is  often  present,  and  sometimes 
to  an  extreme  degree.  The  pia  is  somewhat  thickened 
uniformly  over  the  entire  cortex,  may  contain  many 
corpora  amylacea,  and  is  almost  always  edematous.  The 
convolutions  are  narrow  and  shrunken,  and  the  gaping 
fissures  contain  blebs  filled  with  serous  fluid.  Minute 
hemorrhages  are  sometimes  found  in  the  cortex,  corona 
radialis,  and  basal  ganglia.  The  ventricles  are  much  dilated 
and  ependymal  walls  thickened,  and  occasionally  granular. 
The  choroid  plexuses  usually  present  various  stages  of  cystic 
degeneration.  The  cerebral  vessels  exhibit  arteriosclerosis, 
in  which  there  are  often  evidences  of  hyaline  changes,  but  it  is 
more  characteristic  of  the  vessels  in  senile  dementia  to  show  a 
rich  pigmentation  of  the  endothelial  and  adventitial  cells. 
The  fact  that  the  blood  vessels,  in  simple  senile  deterioration, 
are  only  moderately  involved,  favors  the  view  that  the 
vascular  changes  in  senile  dementia  cannot  be  regarded  as 
the  particular  cause  of  the  disease.  Further  proof  of  this  is 
found  in  the  fact  that  there  are  many  individuals  with  exten- 
sive vascular  lesions  of  the  brain  who  do  not  exhibit  signs 
of  senile  dementia.  Nevertheless,  more  or  less  extensive, 
vascular  lesions  commonly  accompany  senile  dementia. 
There  occasionally  occur  combined  forms  of  senile  and 
arteriosclerotic  insanity,  called  by  Alzheimer  "  senile  de- 
cay" (see  p.  334). 


SENILE  DEMENTIA  371 

Microscopically,  the  nerve  cells  present  different  grades 
of  the  chronic  cell  change  in  addition  to  much  pigmentation. 
Complicating  the  chronic  cell  change  there  may  occur  any  of 
those  acute  cell  changes  described  in  paresis  (see  p.  282). 
Both  the  tangential  and  radical  fibre  tracts  in  the  corona 
present  more  or  less  atrophy.  The  neuroglia  cells  are  more 
numerous  and  show  an  increase  in  the  number  of  nuclei, 
the  cell  bodies  often  forming  distinct  clumps  (rasen)  with  a 
thick  network  of  fine  glia  fibrils.  Many  of  the  neuroglia  cells 
show  evidences  of  extensive  degenerative  processes ;  such  as, 
vacuolization,  marked  pigmentation,  and  atrophy  of  the 
nucleus.  The  spinal  cord  presents  an  atrophy  in  its  ganglion 
cells  and  fibre  tracts.  Calcareous  placques  are  sometimes 
found  in  the  pia.  The  entire  pathological  picture,  however, 
varies,  as  well  as  the  clinical  picture,  but  as  yet  it  is  impossible 
to  establish  any  definite  relationship  between  the  different 
pathological  and  clinical  pictures. 

The  other  organs  of  the  body  present  senile  atrophy  and 
arteriosclerotic  changes.  The  condition  of  the  heart,  with 
chronic  endocarditis  and  fibroid  changes  in  the  myocardium, 
is  of  importance,  as  it  interferes  with  cerebral  circulation. 

Symptomatology.  —  The  apprehension  of  external  im- 
pressions is  slow  and  difficult.  The  patients  fail  to  note 
details  and  to  understand  the  connection  of  things  that  are 
complicated.  They,  therefore,  become  easily  disoriented, 
cannot  see  the  point  in  a  discussion,  and  overlook  important 
matters.  They  are  drowsy,  disinclined  to  think,  somewhat 
dazed,  and  easily  lose  the  thread  of  a  conversation.  Thought 
becomes  stagnant  and  the  patients  are  unable  to  change  their 
viewpoints  or  to  gain  new  ones.  The  old  trains  of  thought, 
being  inaccessible  to  new  ideas,  do  not  get  beyond  the  beaten 
paths.  Ideas,  once  aroused,  are  constantly  recurring,  with- 
out any  regard  for  the  circumstances.    The  mental  elabora- 


372  FORMS  OF  MENTAL  DISEASE 

tion  of  external  impressions,  the  consideration  of  cause  and 
effect,  and  the  critical  examination  of  ideas  is  always  in- 
adequate and  uncertain.  This  explains  the  patients' 
total  inability  to  comprehend  the  views  and  conditions  of 
others,  as  well  as  the  inflexibility  of  their  opinions  and  their 
susceptibility  to  delusional  ideas.  Their  delusional  ideas 
consist  mostly  of  excessive  fear  of  illness,  senseless  distrust, 
or  childish  egoism.  Other  prominent  delusions  are  those  of 
reference  and  robbery.  They  commonly  believe  that  many 
things  are  done  to  annoy  them  and  that  their  property  has 
been  taken  from  them.  A  lack  of  genuine  insight  into 
their  infirmity,  necessitating  the  appointment  of  a  trustee 
or  conservator,  creates  still  other  ideas  of  persecution. 
Hallucinations  and  especially  illusions  are  common. 

The  failure  of  memory  is  always  a  prominent  symptom, 
especially  memory  for  recent  events.  Present  and  passing 
events  within  a  short  time  seem  to  be  completely  effaced 
from  memory.  Patients  forget  where  they  were  yesterday,  or 
where  they  have  placed  things,  do  not  realize  that  they  are 
relating  the  same  story  that  they  told  yesterday  or  perhaps  a 
few  hours  ago,  cannot  recall  the  names  of  recent  acquaint- 
ances, and  even  forget  the  names  of  old  friends.  On  the 
other  hand,  memory  for  events  of  early  life  is  well  retained 
and  furnishes  the  chief  topics  for  conversation.  The  gaps 
of  recent  memory  are  very  often  made  good  by  extensive 
fabrications.  Finally,  as  the  result  of  the  progressive  impair- 
ment of  memory,  to  which  nothing  new  is  ever  added,  there 
develops  an  increasing  impoverishment  of  the  store  of  ideas, 
with  an  extraordinary  dearth  and  uniformity  of  the  content 
of  thought. 

In  emotional  attitude,  indifference  and  lack  of  sympathy 
are  the  prominent  characteristics.  The  patients  become 
apathetic;   they  fail  to  enter  into  the  sorrows  and  joys  of 


SENILE  DEMENTIA  373 

those  about  them,  and  do  not  grieve  at  the  loss  of  friends. 
Self-interest,  with  the  gratification  of  personal  whims,  pre- 
cedes everything.  They  are  no  longer  interested  in  their 
family  or  home.  This  may  advance  to  genuine  avarice,  the 
feeling  of  greed  overwhelming  even  filial  affection.  The 
fundamental  emotional  tone  is  sometimes  that  of  surly  dis- 
satisfaction, and  at  others  a  childish  happiness  and  an 
exalted  self-confidence.  There  may  be  irritability  for  short 
periods.  The  patients  are  inconsiderate,  arbitrary,  dogmatic, 
and  offended  at  any  opposition.  The  emotional  states  are 
both  superficial  and  transitory;  extreme  and  tearful  sym- 
pathy or  silly  happiness  may  be  aroused  on  the. slightest  pre- 
text and  just  as  rapidly  disappear.  The  sexual  feelings  are 
frequently  increased,  impelling  the  patients  to  enter  into 
improper  sexual  relations,  especially  with  children;  to  use 
obscene  language,  to  dress  in  an  attractive  manner,  plan 
marriages,  and  in  extreme  conditions  to  expose  themselves. 
The  conduct  of  the  patients  varies  greatly.  Many  remain 
quiet,  orderly,  and  contented,  and,  in  spite  of  increasing  de- 
mentia, cause  no  trouble  and  can  be  kept  at  home.  Other 
patients  gradually  develop  an  increasing  restlessness:  they 
grumble,  quarrel,  curse,  abuse  those  about  them  at  every  op- 
portunity, and  often  threaten  and  become  aggressive.  Many 
patients  begin  to  idulge  in  excesses,  to  masturbate,  to  wander 
away  from  home,  to  make  foolish  purchases  and  plans,  to 
hoard  all  sorts  of  plunder,  and  ultimately  get  themselves  into 
many  difficulties.  But  nocturnal  restlessness  is  most  charac- 
teristic. It  consists  in  getting  out  of  and  dishevelling  the 
bed,  wandering  about  the  house  with  a  fight,  and  rummaging 
chests  and  closets  without  evident  purpose.  During  the  day 
these  patients  are  weary  and  drowsy  and  frequently  fall  to 
sleep  during  conversation  and  meals.  Patients  are  unable  to 
care  for  themselves  properly  and  are  dirty  about  their  clothing. 


374  FORMS  OF  MENTAL  DISEASE 

Physical  Symptoms.  —  In  addition  to  the  insomnia,  there 
is  usually  a  pronounced  deterioration  in  the  general  physique 
and  some  anorexia.  The  patients  usually  look  older  than 
they  really  are,  the  musculature  is  reduced,  and  the  strength 
below  par.  A  fine  tremor  is  characteristic  of  the  senile,  and 
can  be  distinguished  from  the  tremor  of  the  paretic  and  the 
alcoholic  by  the  numerous  irregularities  in  the  separate 
strokes.  Furthermore,  there  are  a  series  of  physical  symp- 
toms corresponding  to  the  cortical  lesions;  namely,  headache, 
vertigo,  convulsive  seizures  with  transitory  or  permanent 
aphasic  symptoms,  hemianesthesias,  hemianopsia,  ptosis, 
hemiparesis  of  the  muscles  of  the  eye,  tongue,  or  extremities. 
The  pupils  are  sometimes  small,  or  unequal,  and  react  slug- 
gishly or  not  at  all.  The  reflexes  are  usually  increased, 
seldom  diminished.  The  speech  is  often  indistinct. 
Neuritic  disturbances  are  frequent.  Finally,  evidences  of 
arteriosclerosis  are  frequently  observed. 

In  the  severer  grade  of  senile  dementia  there  develops  great 
clouding  of  consciousness  and  complete  disorientation.  These 
patients  apprehend  what  is  said  to  them  and  respond  briefly 
in  a  sensible  manner,  but  they  are  wholly  unable  to  grasp 
what  is  taking  place  about  them.  They  have  no  idea  of 
where  they  are,  address  their  associates  by  the  names  of 
friends  long  since  dead,  and  even  fail  to  recognize  their 
relatives.  They  have  very  little  memory  for  what  occurs  in 
their  daily  lives,  and  gradually  lose  even  their  remote  knowl- 
edge. They  cannot  tell  how  old  they  are,  or  how  many 
children  they  have.  They  say  they  are  twenty-five  years  of 
age,  have  had  twenty-five  children,  the  oldest  of  which  is 
twenty-five  years,  that  they  still  menstruate,  and  are  now 
pregnant.  They  undress  at  midday,  thinking  it  night,  and 
call  the  physician  by  their  husbands'  names.  They  are 
easily  distracted  and  cannot  hold  long  to  one  thought. 


SENILE  DEMENTIA  375 

The  store  of  ideas  is  greatly  impoverished  and  the  same  re- 
marks are  repeated  over  and  over  again.  They  occasionally 
indulge  in  a  peculiar  senseless  rhyming  and  a  half-singing 
repetition  of  words  and  syllables. 

Numerous  changing  fantastic  delusions  are  present,  both 
depressive  and  expansive,  and  often  also  hypochondriacal 
and  nihilistic.  They  cannot  speak,  eat,  or  sleep;  nothing  has 
passed  their  bowels  in  weeks,  and  the  liver  has  rotted  away. 
They  have  leaned  against  a  radiator  and  burned  a  hole  in  the 
lungs  which  has  caused  the  heart  to  cease  beating.  Their 
abdomens  have  been  cut  open  and  organs  removed,  or  they 
will  be  buried  alive.  On  the  other  hand,  they  may  claim 
that  they  possess  much  property,  hold  an  important  position, 
or  are  in  communication  with  God.  The  delusions  are  apt  to 
be  embellished  with  numerous  fabrications.  Hallucina- 
tions of  sight  and  hearing  are  frequently  present. 

The  emotional  attitude  varies.  The  patients  are  sometimes 
apprehensive  and  dejected,  sometimes  irritable,  and  at  others, 
elated  and  happy,  while  rapid  changes  from  one  mood  to 
another  are  common.  In  actions  they  display  more  or  less 
restless  activity,  which  is  especially  marked  at  night.  They 
regularly  tear  and  throw  about  their  bedding,  creep  about  the 
room,  picking  into  the  corners,  destroying  and  smearing 
their  clothing,  or  they  laugh,  sing,  and  run  about  in  a  silly 
manner.  They  are  very  untidy,  and  wholly  incapable  of 
caring  for  themselves.  Insomnia  is  pronounced,  and  very 
little  nourishment  is  taken. 

In  the  group  of  cases  of  senile  dementia  called  pres- 
byophrenia, the  patients,  in  spite  of  a  marked  disturbance  of 
the  impressibility  of  memory,  retain  fairly  well  their  mental 
alertness,  the  coherence  of  thought,  and  to  a  certain  extent,  also, 
good  judgment.  Women  predominate  in  this  group,  and 
chiefly  robust  individuals  are  affected.    Usually  the  disease 


376  FORMS  OF  MENTAL  DISEASE 

develops  gradually,  sometimes  following  more  or  less  definite 
prodromal  symptoms  which  have  been  in  existence  for  some 
weeks.  It  may  appear  as  an  episode  during  the  course  of 
simple  senile  deterioration. 

The  patients  are  capable  of  entering  into  a  long  conversa- 
tion, and  of  comprehending  in  great  measure  the  occurrences 
in  their  environment,  but  they  utterly  fail  in  obtaining  any 
conception  of  their  own  condition  or  of  their  relation  to  the 
environment.  They  forget  almost  immediately  what  they 
have  been  doing  or  what  they  have  heard.  Only  an  oc- 
casional impression  is  retained,  and  especially  those  ac- 
companied by  some  feeling.  Place  and,  particularly,  time 
orientation  is  disturbed.  Patients  cannot  tell  where  they  are 
or  those  about  them.  They  greet  strangers  as  acquaintances ; 
regretting  that  they  cannot  just  recall  the  name,  but  they  are 
confident  that  they  have  seen  them  before.  They  know 
neither  the  day  nor  the  week.  They  make  all  sorts  of  con- 
tradictory statements  as  to  their  age,  speak  as  if  their  parents 
were  still  living,  and  refer  to  their  own  infant  children.  The 
store  of  knowledge  also  is  faulty.  Their  ability  to  reckon  may 
be  fairly  well  retained,  as  well  as  knowledge  of  the  small 
affairs  of  daily  life,  like  the  price  of  articles  of  food,  cooking 
receipts,  etc.,  but  all  beyond  that  is  lost.  They  cannot  recall 
historical  and  geographical  facts,  the  name  of  the  President, 
and,  indeed,  sometimes  even  the  names  and  ages  of  their  own 
children,  but  yet  they  may  be  able  to  recall  a  few  remote 
facts,  as  their  own  maiden  name  and  the  playmates  of  their 
childhood. 

The  patients  do  not  appreciate  these  marked  defects. 
When  quizzed,  they  will  explain  their  inability  to  answer  such 
questions  by  the  fact  that  they  were  never  interested  in  such 
things,  that  women  are  not  supposed  to  bother  about  such 
matters,  etc.    They  usually  make  good  the  lapses  in  their 


SENILE  DEMENTIA  377 

recent  memories  by  simple  fabrications;  such  as,  that  they 
were  busy  in  the  morning,  had  been  out  to  call  on  their 
parents,  other  relatives  were  there,  and  they  all  drank  some 
coffee.  Now  they  have  come  here  to  help  with  some  work, 
but  are  soon  going  to  return  to  their  place  of  employment, 
where  they  are  earning  good  wages.  These  patients  rarely 
express  delusions  or  have  hallucinations. 

Their  judgment  is  fairly  well  retained  as  far  as  it  involves 
their  early  knowledge  and  facts  which  are  at  their  disposal. 
For  instance,  such  senseless  expressions  as  that  "  the  snow  is 
black,"  or  "  that  ball  is  square"  cause  them  to  smile,  and 
they  become  indignant  if  told  that  they  steal  or  perjure  them- 
selves. On  the  other  hand,  the  patients  fail  to  recognize  the 
most  absurd  contradictions  as  regards  the  temporal  relation 
of  events,  even  when  their  attention  is  called  to  them.  They 
will  say  that  their  parents  are  no  older  than  they,  that  their 
daughter  is  only  three  years  younger,  though  she  was  born 
more  than  ten  years  ago.  In  their  conversation  the  patients 
are  often  energetic  and  loquacious,  although  they  frequently 
digress. 

The  emotional  attitude  of  the  patients  is  usually  that  of 
happiness  with  an  occasional  brief  show  of  peevishness  or 
irritability.  They  exhibit  an  interest  and  readily  familiarize 
themselves  with  their  environment  and  can  appreciate  a  joke. 
In  conduct  they  are,  in  general,  orderly,  and  busy  themselves 
in  one  way  or  another.  Occasionally  there  is  some  nocturnal 
restlessness.  Symptoms  of  severe  brain  lesions,  particularly 
paralysis  and  apoplectic  attacks,  are  rarely  encountered. 

This  picture  of  presbyophrenia  may  persist  unchanged  for 
a  number  of  years.  Again  it  may  pass  over  into  a  state  of 
simple  stupid  dementia. 

Senile  Delirium.  —  This  form  is  characterized  by  a  more 
acute  onset  and  a  short  course  with  great  clouding  of  conscious- 


378  FORMS  OF  MENTAL  DISEASE 

ness,  active  hallucinations,  and  delirious  conduct.  It  often 
appears  as  an  episode  in  the  course  of  senile  deterioration ; 
indeed,  signs  of  beginning  senile  dementia  usually  precede 
the  outbreak.  Exciting  causes  are  prominent;  such  as 
acute  illnesses,  mental  shock,  or  injuries. 

The  patients  rapidly  develop  many  hallucinations  of  sight 
and  hearing.  They  hear  voices,  threats,  singing,  see  the 
devil,  or  crowds  of  men  pressing  upon  them  with  knives. 
They  are  anxious  and  restless,  claiming  that  they  are  in  the 
world  below,  surrounded  by  mighty  powers,  are  bewitched 
and  poisoned,  the  house  is  being  flooded  and  huge  boulders 
rolled  about  the  room.  Disorientation  is  complete.  The 
speech  is  irrelevant,  incoherent,  and  flighty,  and  is  often 
limited  to  unintelligible,  disjointed  words,  or  to  a  repetition 
of  senseless  syllables.  There  is  usually  great  pressure  of 
speech.  The  activity  is  greatly  increased;  they  rattle  doors 
and  windows,  shout  for  help,  refuse  food,  resist,  tear  up  the 
bedding,  and  crawl  about  the  floor,  etc.  Insomnia  is 
extreme. 

The  course  of  the  delirium  presents  many  fluctuations  and 
sudden  remissions,  with  more  or  less  complete  return  to  clear 
consciousness.  The  delirium  may  reappear  after  a  short 
interval,  or  it  may  pass  over  into  a  state  of  anxiety  with 
peevishness,  which  may  persist,  or  in  time  entirely  disappear. 
In  unfavorable  cases  the  delirium  becomes  extreme,  leading 
to  collapse  and  death  from  exhaustion,  injuries,  or  acute 
febrile  diseases. 

Finally,  there  is  a  characteristic  group  of  cases  in  senile 
dementia  which  has  been  called  senile  delusional  insanity. 
These  cases  develop  gradually.  The  patients  become  reti- 
cent, irritable,  and  suspicious.  It  soon  becomes  apparent 
that  they  are  dominated  by  delusions  ;  that  they  believe  that 
they  are  being  robbed,  are  being  ridiculed  and  insulted  by 


SENILE  DEMENTIA  379 

their  neighbors,  and  are  hindered  in  their  work ;  that  poison 
is  being  placed  in  their  food.  These  delusions  are  ap- 
parently scanty,  somewhat  incoherent,  and  are  rarely  elabo- 
rated, though  they  may  remain  unchanged  a  long  time. 
Hallucinations  are  often  present,  especially  in  deaf  patients. 
The  patients  remain  completely  oriented.  However,  per- 
sons in  the  environment,  who  are  involved  in  their  delusions, 
may  be  mistaken  for  others.  The  emotional  attitude  usually 
becomes  indifferent,  though  occasionally  the  patients  are  irri- 
table and  egotistical.  In  conduct  they  are  orderly  and  tract- 
able; they  busy  themselves  and  only  occasionally  are  excited. 

Diagnosis.  —  The  physiological  changes  common  to 
normal  senility,  such  as  the  defect  in  the  impressibility  of 
memory,  an  impoverishment  of  the  store  of  ideas,  an  emo- 
tional indifference,  a  paralysis  of  activity,  and  the  develop- 
ment of  stubborn  unruliness,  renders  very  difficult  the 
differentiation  of  the  milder  forms  of  senile  dementia.  To  a 
certain  extent  this  distinction  is  wholly  arbitrary.  The 
appearance  of  delusions  and  of  excitement  should  leave  no 
doubt  as  to  the  presence  of  a  psychosis.  The  depressive 
states  in  senile  dementia  may  be  differentiated  from  melan- 
cholia by  the  dearth  and  the  incoherence  of  the  delusions  and 
the  defective  memory  and  emotional  dulness. 

The  differentiation  of  senile  dementia  from  arteriosclerotic 
insanity  is  difficult.  It  has  already  been  indicated  that  focal 
symptoms  of  themselves  are  not  particularly  characteristic 
of  senile  dementia,  and  point  only  to  the  fact  that  there  is 
an  accompanying  vascular  disease.  Therefore,  the  more 
prominent  such  symptoms  are,  the  greater  the  role  of 
arteriosclerotic  changes.  Inversely,  a  rapid  and  general 
decay  of  the  mental  activity,  particularly  a  severe  disorder 
of  memory,  indicates  senile  dementia.  The  same  observa- 
tion holds  true  in  syphilitic  insanity,  in  which  the  dementia 


380  FORMS  OF  MENTAL  DISEASE 

never  becomes  very  pronounced  until  after  a  long  duration, 
while  hallucinations  and  delusions  are  more  prominent. 

The  senile  delirium,  except  for  the  underlying  basis  of 
deterioration,  does  not  differ  from  the  delirium  encountered 
in  other  psychoses. 

Treatment.  —  The  treatment  is  wholly  symptomatic.  The 
condition  of  faulty  nutrition  needs  careful  watching  in  order 
to  secure  the  ingestion  of  a  sufficient  amount  of  easily  di- 
gested food.  The  insomnia  of  the  senile  is  most  intractable. 
In  combating  it,  one  should  first  employ  the  simplest  reme- 
dies; as,  warm  nourishment  at  the  time  the  patient  awakes 
after  the  sleep  of  the  early  night,  prolonged  warm  baths,  and 
sufficiently  warm  bed  clothing,  together  with,  if  necessary, 
hot-water  bottles.  Warm  packs  should  be  employed  most 
cautiously.  Of  the  hypnotic  remedies,  alcohol  is  most  useful. 
Paraldehyde,  chloralamide,  and  somnos  are  at  times  also 
efficient.  Occasionally  small  and  repeated  doses  of  nitro- 
glycerin give  excellent  results.  These  patients,  if  kept  at 
home,  must  be  watched  closely  at  night,  and  placed  in  rooms 
without  lights  and  with  guarded  windows  in  order  to  prevent 
injuries  to  self  and  danger  from  fire  to  others.  If  the  in- 
somnia and  restlessness  become  extreme,  the  prolonged  warm 
bath  (see  p.  140)  may  be  used.  Failing  in  this,  one  should 
improvise  a  padded  room  or  a  bed  with  high  padded  sides. 
In  the  cases  accompanied  by  great  anxiety,  opium  (see  p.  362) 
is  indicated  and  often  brings  the  desired  relief. 


IX.   MANIC-DEPRESSIVE   INSANITY1 

Manic-depressive  insanity  is  characterized  by  the  recurrence 
of  groups  of  mental  symptoms  throughout  the  life  of  the  in- 
dividual, not  leading  to  mental  deterioration.  These  groups 
of  symptoms  are  sufficiently  well  defined  to  be  termed  the 
manic,  the  depressive,  and  the  mixed  phases  of  the  disease. 
The  chief  symptoms  usually  appearing  in  the  manic  phase 
are:  psychomotor  excitement  with  pressure  of  activity,  flight 
of  ideas,  distractibility,  and  happy  though  unstable  emo- 
tional attitude.  In  the  depressive  phase  we  expect  to  find 
psychomotor  retardation,  absence  of  spontaneous  activity, 
dearth  of  ideas,  and  depressed  emotional  attitude;  while  the 
symptoms  of  the  mixed  phase  consist  of  various  combinations 
of  the  symptoms  characteristic  of  both  the  manic  and  depres- 
sive phases. 

Etiology.  —  Manic-depressive  insanity  is  one  of  the  most 
prominent  forms  of  mental  disease,  and  comprises  from 
twelve  to  twenty  per  cent,  of  admissions  to  insane  hospitals. 
Of  the  etiological  factors,  defective  heredity  is  the  most  im- 
portant, occurring  in  from  seventy  to  eighty  per  cent,  of 

1  Kim,  Die  periodischen  Psychosen,  1878 ;  Mendel,  Die  Manie,  eine 
Monographie,  1881 ;  Emmerich,  Schmidt's  Jahrbucher,  CXC,  2 ;  Pick, 
Circulares  Irresein,  Eulenburgs  Realencyclopsedie,  2.  Auflage;  Hoche, 
Ueber  die  leichteren  Formen  des  periodischen  Irreseins,  1897;  Hecke, 
Zeitschrift  fur  praktische  Aertze,  1898,  1 ;  Pilcz,  Die  periodischen  Geis- 
tesstorungen,  1901 ;  Thalbitzer,  Den  manio-depressive  Psykose,  Stem- 
mingssindsygdom,  1902;    Hoch,  Ref.  Hand.  Med.  Soc,  Vol.  V,  120. 

381 


382  FORMS  OF  MENTAL  DISEASE 

cases.  The  relatives  have  often  suffered  from  the  same  form 
of  disease.  The  defective  constitutional  basis  is  often  ap- 
parent in  individuals  previous  to  the  onset  of  the  psychosis; 
some  are  peculiar,  some  are  abnormally  bright,  others  are 
of  an  excitable  disposition  and  subject  to  frequent  and  ap- 
parently causeless  changes  of  mood,  and  still  others  are  exces- 
sively shy  and  reserved;  while  a  few  are  imbecile  from  birth. 
Physical  stigmata  may  also  be  present.  Women  predominate 
in  the  disease  and  represent  about  two-thirds  of  the  patients. 
The  disease  almost  always  appears  independently  of  exter- 
nal causes.  In  a  few  cases  the  appearance  of  the  first 
attack  is  coincident  with  the  first  menstruation.  The  first 
and  subsequent  attacks  may  occur  during  succeeding 
periods  of  childbearing,  but  it  is  also  a  conspicuous  fact  that 
the  attacks  do  not  cease  at  the  climacterium.  In  two- 
thirds  of  the  cases  the  first  attack  appears  before  twenty-five 
years  of  age,  and  in  less  than  ten  per  cent,  after  the  for- 
tieth year,  in  both  of  which  periods  women  greatly  predomi- 
nate. The  first  attack  may  occur  as  early  as  ten  years  of 
age,  and  as  late  as  seventy  years. 

The  nature  of  manic-depressive  insanity  is  still  obscure. 
Several  hypotheses  have  been  formulated,  but  none  are  ade- 
quate. There  are  no  demonstrable  anatomical,  pathological 
lesions  characteristic  of  this  disease. 

Symptomatology.  —  Apprehension  of  external  impressions 
in  the  manic  states,  with  the  exception  of  hypomania,  is 
more  or  less  disturbed.  This  disturbance  is  due  largely  to  the 
great  distractibility  of  attention.  The  patients  lose  the 
ability  to  select  and  elaborate  their  impressions,  because  each 
striking  sensory  stimulus  forces  itself  upon  them  so  strongly 
that  it  absorbs  their  entire  attention.  Their  attention  may 
be  held  for  a  moment  by  holding  objects  before  them,  but 
it  is  quickly  distracted  by  something  else.     Hence,   the 


MANIC-DEPRESSIVE  INSANITY  383 

environment  is  never  fully  apprehended,  and  the  picture 
remains  disconnected  and  incomplete,  although  there  is  no 
serious  disorder  of  the  perceptive  process.  In  the  depressive 
forms  apprehension  is  more  manifestly  and  extensively 
disturbed;  especially  is  this  true  in  stupor.  Even  in  the 
lighter  depressive  states  the  patients  are  unable  to  elaborate 
and  comprehend  well  their  impressions. 

Consciousness  is  regularly  disturbed  in  the  severer  forms 
of  the  disease.  At  the  height  of  the  manic  excitement 
the  hazy  impressions  lead  to  disorientation.  Patients 
do  not  correctly  understand  where  they  are,  mistake  persons, 
and  greet  the  physicians  and  nurses  by  the  names  of  relatives 
or  neighbors.  This  mistaking  of  persons  sometimes  arises 
from  slight  similarities  of  dress  or  facial  expression,  but  at 
other  times  it  seems  to  be  due  altogether  to  the  capricious- 
ness  of  the  patients.  In  the  less  severe  manic  forms  con- 
sciousness is  very  slightly  disturbed.  On  the  other  hand,  in 
the  depressive  states  of  the  disease  consciousness  is  more 
clouded,  particularly  in  the  stuporous  conditions. 

Hallucinations  are  rare,  except  in  the  delirious  form  of 
the  manic  phase,  and  in  the  more  marked  stuporous  depres- 
sive conditions,  but  even  here  they  are  neither  a  prominent 
nor  persistent  feature.  Furthermore,  the  hallucinations 
do  not  have  the  same  sensory  distinctness  common  to  the 
sense  deceptions  of  dementia  prsecox.  On  the  other  hand, 
numerous  and  varied  false  sensations  often  accompany  the 
pronounced  hypochondriacal  fears  of  the  depressive  patients. 
These  are  experienced  all  over  the  body.  Patients  claim 
that  they  feel  the  food  as  it  courses  through  the  veins,  that 
they  feel  their  organs  being  consumed,  that  nerves  are  dis- 
solving, and  that  little  white  worms  are  crawling  under  the 
skin,  etc.  This  increased  sensitiveness  to  the  internal 
processes  of  the  body  stands  out  in  contrast  to  the  loss  of 


384  FORMS  OF  MENTAL  DISEASE 

central  sensitiveness  to  external  impressions  in  the  manic 
states,  as  seen  in  the  remarkable  insensibility  of  the  manic 
patients  to  extremes  of  heat  and  cold,  to  hunger,  and  to 
pain. 

Memory  does  not  suffer  much  injury  from  the  disease 
itself,  although  patients  often  temporarily  lose  control 
over  their  store  of  ideas.  Especially  in  the  depressive 
states  the  patients  are  often  unable  to  recall  even  simple 
facts.  It  takes  them  a  very  long  time  to  solve  a  simple 
problem  or  to  relate  some  experience.  During  the  disease 
process  the  impressibility  of  memory  is  impaired.  It  has 
been  shown  by  special  tests  that  manic  patients  make  more 
errors  than  normal  individuals  in  recalling  to  memory  their 
perceptions.  There  is  sometimes  a  tendency  to  fabrica- 
tions and  to  depict  grotesque  experiences.  Memory  for 
events  of  the  attack  is  usually  somewhat  indistinct,  par- 
ticularly where  there  has  been  pronounced  excitement  or 
profound  stupor. 

Delusions  are  often  present  in  manic-depressive  insanity. 
In  the  manic  phases  they  are  changeable  and  frequently 
appear  in  the  form  of  playful  boasts  and  exaggerations. 
Where  the  consciousness  is  somewhat  clouded,  the  patients 
tend  to  elaborate  more  permanent  expansive  and  persecu- 
tory delusions,  the  latter  being  directed  particularly  against 
the  family;  also  delusions  of  jealousy  and  poisoning. 
In  the  depressive  states  hypochondriacal  ideas  are  most 
prominent,  and  are  often  associated  with  delusions  of  perse- 
cution and  of  self-accusation.  The  depressive  delusions 
sometimes  beome  markedly  fantastic,  similar  to  those 
expressed  by  paretics.  Patients  usually  express  some 
insight;  they  appreciate  having  undergone  a  change,  but 
they  are  quite  apt  to  attribute  it  to  misfortune  or  abuse  of 
some  sort,  rather  than  to  mental  illness. 


MANIC-DEPRESSIVE  INSANITY  385 

Disturbances  of  thought  are  prominent  symptoms.  In 
the  manic  states  a  definite  line  of  thought  cannot  be  followed 
out;  ideas  pass  abruptly  from  one  subject  to  another,  and 
the  line  of  discourse  is  lost  in  a  mass  of  detail.  A  short 
question  may  be  answered  correctly,  but  with  the  addition 
of  a  host  of  details  and  side  remarks  that  have  only  a  distant 
relation  to  the  subject  —  circumstantiality.  It  is  impossible 
for  the  patients  to  relate  any  event  coherently  without 
frequent  inquiries  and  suggestions  on  the  part  of  the  listener 
to  recall  him  from  his  digressions .  There  is  a  lack  of  voluntary 
guidance  of  the  train  of  thought ;  hence  there  are  abrupt 
changes  in  the  succession  of  ideas  influenced  by  objects  that 
happen  to  come  into  the  field  of  vision,  or  by  sounds  caught 
up  from  the  surroundings.  On  the  whole,  there  is  a  multi- 
tude of  ideas  which  are  not  well  connected.  There  is 
no  controlling  goal  idea.  The  association  of  ideas  follows 
along  accustomed  tracks,  especially  those  that  play  an 
important  part  in  daily  expressions;  such  as  bits  of  slang 
and  common  phrases.  The  resulting  incoherence  of  thought 
gives  rise  to  the  so-called  flight  of  ideas.  Observation  of 
external  objects  may  seem  to  be  very  accurate  and  com- 
plete, but  in  reality  it  is  superficial.  A  striking  object  at- 
tracts the  attention,  is  apprehended,  and  starts  a  train  of 
thought,  but  before  this  has  proceeded  far  something  else 
obtrudes  upon  the  sensorium,  and  another  is  started.  In 
spite  of  appearances,  genuine  thought  is  delayed.  Instead 
of  an  acceleration  of  the  train  of  ideas,  there  is  only  flightiness 
and  an  instability.  There  is  an  abundance  of  words,  not 
of  ideas.  Sometimes  in  the  depressive  forms  there  is  a 
slight  degree  of  flight  of  ideas. 

As  a  counterpart  to  flight  of  ideas,  we  have  retardation 
of  thought,  which  regularly  accompanies  the  depressive 
phases  of  the  disease,  and  also  some  of  the  manic-stuporous 

2c 


386  FORMS  OF  MENTAL  DISEASE 

states  and  the  forms  of  manic  excitement  allied  to  them. 
Patients  seem  unable  to  marshal  their  ideas,  and  are  often 
painfully  aware  of  this.  The  individual  ideas  seem  to  develop 
slowly  and  only  after  very  strong  stimuli.  Hence,  external 
impressions  do  not  quickly  and  easily  arouse  a  group  of 
associations,  but  the  train  of  thought  has  to  progress  slowly 
and  requires  an  especial  effort  of  the  will.  On  the  other 
hand,  an  idea  once  developed  is  not  pushed  aside  by  the  ap- 
pearance of  new  ideas,  but  it  fades  slowly  and  often  sticks 
with  great  persistency,  especially  if  it  arises  in  connection 
with  some  feeling.  Thus  there  result  great  difficulty  and 
slowness  of  thought,  monosyllabic  answers  to  simple  ques- 
tions, and  a  dearth  of  ideas.  This  is  apt  to  be  regarded  as 
evidence  of  dementia,  until  close  observation  demonstrates 
that  there  is  no  real  deterioration. 

The  emotional  attitude  in  the  manic  forms  shows  more  or 
less  elation  and  happiness.  There  is  a  feeling  of  well- 
being  with  a  tendency  to  joke  and  to  make  facetious  remarks. 
Expressions  of  emotion  are  unrestrained.  Irritability  is 
prominent,  giving  rise  at  times  to  outbursts  of  anger  from 
trivial  causes,  but  rapid  changes  in  the  emotional  attitude 
are  still  more  characteristic:  in  the  midst  of  joy  patients 
become  tearful,  and  complain  of  abuse  and  misfortune; 
again,  in  spite  of  profound  misery,  they  may  burst  out  into 
boisterous  laughter.  These  varying  states  appear  and 
disappear  with  the  greatest  rapidity.  Depression  of  spirits 
sometimes  appears  for  a  few  hours  at  a  time  during  manic 
states.  In  the  depressive  states  of  the  disease  the  emotional 
attitude  is  regularly  that  of  gloominess,  despair,  doubt,  and 
anxiety.  Patients  complain  particularly  of  the  loss  of  in- 
terest in  things;  "  everything  is  the  same  to  them,"  "  they 
are  desolate  and  empty,"  "  they  are  dead,  because  they 
have  no  feeling,"  "  music  does  not  sound  natural,"  and 


MANIC-DEPRESSIVE  INSANITY  387 

"  the  crying  of  the  children  no  longer  creates  sympathy." 
They  feel  as  if  they  no  longer  belong  to  this  world.  One 
sometimes  encounters  moments  when  patients  exhibit  feeble 
attempts  at  laughter  and  even  brief  gayety.  There  are 
some  cases  of  simple  retardation  in  which  there  is  no  es- 
pecial emotional  tone.  In  the  transition  states  and  mixed 
phases  there  is  stupor  with  silent  mirth,  or  restless  mis- 
chievousness  with  anxiety. 

The  disturbances  found  in  the  psychomotor  sphere  are 
prominent  symptoms.  In  the  manic  states  the  increased 
facility  for  the  conveyance  of  stimuli  into  action  gives  rise 
to  'pressure  of  activity.  Every  sort  of  impulse  leads  to  an 
action,  completely  inhibiting  all  normal  volitional  impulses, 
or  even  if  a  volitional  action  is  begun,  it  is  overwhelmed 
before  half  accomplished.  Furthermore,  almost  imper- 
ceptible impulses  excite  the  greatest  variety  of  movements, 
which  are  executed  with  unusual  energy.  In  the  mildest 
manic  states  there  appears  a  characteristic  busyness  and 
an  excessive  display  of  energy  over  trifles.  If  the  disease  is 
more  severe,  the  actions  become  disconnected,  and  new 
impulses  intrude  before  any  one  object  can  be  accomplished. 
In  the  severest  excitement,  the  actions  change  as  rapidly 
as  the  ideas.  The  actions,  however,  depend  upon  and  bear 
a  definite  relation  to  the  ideas  and  emotions.  The  intensity 
of  the  motor  excitement  is  due  to  an  increased  irritability 
and  depends  largely  upon  external  stimuli,  the  removal 
of  which  reduces  the  activity.  Unrestrained  activity  tends 
to  increase  the  excitement.  The  ready  release  of  the  motor 
impulses  perhaps  accounts  for  the  unusual  absence  of  fatigue. 
In  these  conditions  excitement  may  persist  for  weeks  or 
even  months  without  any  signs  of  exhaustion. 

The  psychomotor  pressure  of  activity  is  prominent  also 
in  the  field  of  speech,  and  aids  in  the  production  of  flight  of 


388  FORMS  OF  MENTAL  DISEASE 

ideas.  The  easily  aroused  motor-speech  dispositions  have 
a  stronger  influence  in  directing  the  train  of  thought  than 
the  ideas  arising  from  purely  intellective  processes.  In- 
stead of  a  logical  sequence  of  ideas,  we  find  that  motor 
coordinations  determine  their  succession;  thus,  we  encounter 
those  associations  common  in  the  everyday  life;  such  as, 
set  phrases,  slang,  and  rhymes,  and  finally  a  predominance 
of  pure  sound  associations,  when  are  heard  such  productions 
as,  "  Sam,  jam,  bang,  slam,  hell,  shell,  bells,"  etc.  Silence 
is  impossible.  The  patients  prattle  away  and  shout  at  the 
top  of  their  voices,  scream,  declaim  with  many  gestures  and 
in  a  pompous  manner,  perhaps  ending  in  unrestrained 
laughter,  or  they  sing,  now  softly,  now  slowly.  The  fol- 
lowing is  a  sample  of  the  manic  production :  — 

"  I  was  looking  at  you,  the  sweet  voice,  that  does  not  want 
sweet  soap.  You  always  work  Harvard,  for  the  hardware  store. 
Here  is  the  right  hand,  the  hand  that  they  shot  off  yesterday. 
The  love  of  God  don't  win  gray  hairs.  I  don't  care  if  I  am  nine- 
teen, my  father  taught  me  to  love.  Neatness  of  feet  don't  win 
feet,  but  feet  win  the  neatness  of  men.  Run  don't  run  west,  but 
west  runs  east.  I  like  west  strawberries  best.  Rebels  don't  shoot 
devils  at  night.  For  three  years  I  got  over  seven  dollars  a  month 
and  some  old  rags.  Take  your  time  and  be  not  disobedient,  be 
grateful  when  judgment  day  comes.  God's  laws  are  all  right,  but 
Royal  Baking  Powder  is  compressed  yeast.  Women  should  never 
chew  gum.  Women  should  never  smoke.  Women  should  mind 
their  own  business.  Fish-hooks  are  between  the  American  flag, 
red,  white,  and  blue,  Fourth  of  July.  You  must  pay  for  your  own 
fiddler,  Prudence.  I  am  no  tobacco  chewer,  I  am  no  street  walker, 
I  am  vaccinated,  but  McKinley  does  not  win.  My  father  is  a 
Democrat.     He  had  no  work  for  three  years." 

Such  incoherence  is  not  the  outcome  of  an  excessive 
repletion  of  ideas,  but  results  from  an  inability  to  give 
direction  to  the  train  of  ideas.    A  normal  individual,  at 


MANIC-DEPRESSIVE  INSANITY  389 

times,  might  give  expression  to  a  similar  production  if  he 
could  utter  a  sequence  of  ideas  as  they  came  into  his  mind. 
In  the  disease  picture  this  ideomotor  excitability  regularly 
leads  to  the  expression  of  every  idea  that  presents  itself. 

The  letter-writing  of  manic  patients  shows  with  equal 
clearness  the  same  disturbance.  Single  phrases  and  sen- 
tences may  be  well  started,  but  are  soon  resolved  into  a 
senseless  enumeration  of  catch  phrases,  bits  of  slang,  and 
rhyme.  The  script  is  coarse  and  bold,  while  underlining, 
overwriting,  and  punctuation  marks  predominate. 

The  psychomotor  field  in  the  depressive  form  presents 
a  retardation  of  activity,  due  to  the  slowness  of  conversion 
of  sensory  and  ideational  stimuli  into  impulses.  In  the 
mildest  degree  this  retardation  appears  as  a  deficiency  in 
the  power  of  resolution.  Actions  may  not  only  be  performed 
slowly,  but  even  after  being  started  may  fail  of  completion. 
The  simplest  movements,  such  as  walking  and  talking,  are 
performed  very  slowly  and  without  energy.  Unless  extreme, 
the  retardation  may  be  overcome  by  an  emotional  excite- 
ment, such  as  impending  danger  or  some  unusual  stimulus. 
In  the  severest  forms  the  retardation  leads  to  a  complete 
abolition  of  all  voluntary  movements,  producing  a  condition 
of  stupor,  when  the  patients  are  unable  to  leave  the  bed  or 
attend  to  their  physical  needs. 

Retardation  may  vary  considerably  in  the  extent  to 
which  it  influences  the  different  spheres  of  voluntary  ac- 
tivity. The  patients  may  perhaps  be  able  to  dress  them- 
selves and  to  employ  themselves  without  difficulty,  but 
they  shrink  from  any  act  that  demands  resolution.  Some 
patients  are  so  taciturn  and  monosyllabic  that  it  is  impos- 
sible to  engage  them  in  conversation,  and  although  they 
are  able  to  count  or  read  aloud  as  rapidly  as  ever,  they  will 
sit  for  hours  with  a  letter  in  front  of  them,  unable  to  finish 


390  FORMS  OF  MENTAL  DISEASE 

writing  it.  Again  there  are  patients  who  read  rapidly,  but 
cannot  write  a  line;  and  there  are  others  who  write  long 
letters,  but  become  speechless  as  soon  as  you  address  them. 
The  symptoms  enumerated  above  portray  the  disease 
picture  as  a  whole.  As  already  indicated,  these  symptoms 
tend  to  arrange  themselves  into  two  large  groups,  represent- 
ing the  manic  and  the  depressive  phases  of  the  disease, 
and  a  third  smaller  group,  the  mixed  phase.  Occasionally, 
individual  cases  fail  to  present  sufficiently  clear  pictures  to 
permit  their  definite  assignment  to  any  one  of  these  phases, 
which  condition,  together  with  the  occurrence  of  numerous 
transition  stages  from  one  phase  to  another,  emphasizes 
the  fact  that  it  is  impossible  to  draw  a  distinct  border 
line  between  the  prominent  phases  of  the  disease. 

Manic  States 

The  manic  states  comprise  hypomania,  mania,  and 
delirious  mania. 

Hypomania  represents  the  mildest  form  of  the  manic 
states,  and  has  been  variously  designated  "  mania  mitis," 
or  "  mitissima,"  and  "  folie  raisonnante." 

Consciousness,  apprehension,  and  memory  are  undisturbed. 
The  activity  of  the  mind  and  of  the  attention  is  often  in- 
creased; indeed,  the  patients  may  appear  brighter  and 
clearer  minded  than  usual,  because  of  their  ability  to  grasp 
faint  resemblances,  but  in  reality  they  cannot  make  use  of 
any  valid  comparisons.  In  the  realm  of  ideation  they  show 
a  moderate  flight  of  ideas,  which  is  more  especially  noticed 
in  letters.  They  shift  abruptly  from  one  subject  to  another, 
and  are  quite  unable  to  bring  a  thought  to  a  logical  conclu- 
sion. They  are  very  talkative,  the  content  of  conversation 
being  centered  about  commonplace  affairs,  their  experiences 
and  difficulties.    They  revel  in  minute  details,  and  often 


MANIC-DEPRESSIVE   INSANITY  391 

distort  the  facts  with  exaggerations  and  frequent  misrepre- 
sentations. In  the  severer  grades  there  is  a  striking  lack 
of  coherence  in  the  train  of  thought.  The  patients  are  unable 
to  arrange  logically  a  series  of  ideas  without  abrupt  transi- 
tions from  one  subject  to  another.  In  their  writings  and 
rhymes  they  often  develop  a  flight  of  ideas.  Upon  effort 
they  may  be  able,  for  short  periods,  to  gain  the  mastery  over 
their  incoherent  thoughts,  as  well  as  over  their  excessive 
activity.  There  may  occur,  for  short  periods,  more  marked 
excitement  and  dazedness. 

Memory  for  recent  events  is  not  always  correct.  Patients 
in  their  conversation  are  easily  carried  away  with  exaggera- 
tions and  distortions,  which  arise  in  part  from  their  keener 
perception  and  in  part  from  accessory  interpretations, 
which  never  really  come  clearly  into  consciousness.  Although 
there  are  no  genuine  delusions,  yet  there  is  a  greatly  exag- 
gerated self-esteem.  Patients  boast  of  their  own  deeds 
and  show  a  proportionate  lack  of  appreciation  for  those  of 
others.  Hence,  they  lack  insight  into  their  condition. 
While  they  may  admit  a  previous  attack,  they  cannot  regard 
their  present  state  as  anything  but  normal.  They  justify 
their  actions  in  a  most  persistent  way,  and  never  lack  plaus- 
ible excuses.  Moreover,  they  believe  themselves  misjudged 
or  falsely  confined,  as  they  never  were  more  healthy  or 
capable  of  work.  Usually,  in  their  estimation,  the  relatives 
and  friends,  or  those  who  have  been  instrumental  in  their 
confinement,  are  the  ones  in  need  of  treatment. 

As  to  the  emotional  attitude  the  patients  are  usually  elated, 
happy,  cheerful,  and  often  exuberant.  They  derive  great 
pleasure  from  their  associations  and  undertakings.  Some 
patients  develop  a  pronounced  humorous  vein  and  a  ten- 
dency to  see  the  funny  side  of  things,  to  make  facetious 
remarks,  to  invent  nicknames,  and  to  make  sport  of  them- 


392  FORMS  OF  MENTAL  DISEASE 

selves  and  others.  They  are  jovial  and  friendly,  but  dis- 
tinctly selfish,  while  their  own  desires  and  wishes  prevail. 
On  the  other  hand,  increased  irritability  may  develop, 
when  the  patients  become  discontented,  intolerant,  and 
quarrelsome  with  their  environment.  They  are  apt  to 
become  inconsiderate,  saucy,  and  rude,  whenever  any  one 
opposes  them.  Insignificant  occasions  may  lead  to  violent 
fits  of  anger  and  even  aggressiveness.  They  are  completely 
under  the  control  of  sudden  impressions  and  emotions, 
which  quickly  acquire  an  irresistible  power  over  them. 
Their  general  conduct  bears  the  stamp  of  impulsiveness 
and  rashness;  hence,  on  account  of  the  slight  disturbance 
of  intellect,  their  conduct  is  often  regarded  as  unscrupulous. 

The  most  striking  symptom  of  all  is  the  increased  psycho- 
motor activity.  The  patients  feel  compelled  to  be  doing 
something  all  the  time.  They  must  take  part  in  whatever 
goes  on  about  them.  Since  the  sense  of  fatigue  is  dimin- 
ished, they  do  not  feel  the  need  for  rest,  so  they  busy  them- 
selves until  late  at  night  and  are  up  again  early  in  the  morn- 
ing, bustling  about  on  all  sorts  of  business.  They  take  long 
walks,  devote  much  time  to  pleasure,  begin  a  diary,  write 
many  letters,  undertake  long  journeys  to  renew  old  acquaint- 
ances, and  do  many  other  things  which  they  never  would 
have  thought  of  before.  They  suddenly  change  their  occu- 
pation, attempt  journalism,  write  verse,  purchase  property, 
give  away  many  presents,  build  castles  in  the  air,  and  start 
in  numerous  undertakings  that  are  beyond  both  their 
capital  and  physical  strength.  Their  actual  capacity  for 
work,  however,  is  much  diminished.  They  lack  persever- 
ance, become  negligent,  and  apply  themselves  only  to  that 
which  is  agreeable. 

In  general  demeanor  it  is  obvious  that  the  patients  are 
self-conscious   and   attempt   to    attract   attention.     They 


MANIC-DEPRESSIVE   INSANITY  393 

dress  in  a  conspicuous  manner,  and  adorn  themselves  with 
flowers  and  cosmetics.  Their  handwriting  is  characteris- 
tically large  and  coarse,  with  a  display  of  many  exclamation 
and  interrogation  marks  and  much  underlining.  In  the 
presence  of  others  they  always  press  forward,  seek  to  assert 
themselves,  talk  a  great  deal,  gesticulate,  and  boast.  They 
are  apt  to  be  discourteous  and  offensive  in  manner.  In 
spite  of  deep  mourning  they  indulge  in  boisterous  pleasures. 
In  the  presence  of  women  they  relate  questionable  tales. 
They  make  free  with  strangers  and  persons  of  high  rank, 
as  if  they  were  old  friends.  Their  tendency  to  indulge  in 
all  sorts  of  extravagances  is  particularly  prominent.  They 
often  begin  to  drink  and  smoke,  remain  out  late  at  night, 
keep  questionable  company,  frequent  saloons,  and  eat  ex- 
cessively of  rich  foods.  Women  are  particularly  apt  to 
show  increased  sexual  desires,  and  to  dress  in  a  striking 
manner,  to  attend  dances,  to  read  trashy  novels,  and  to 
fall  in  love.  Not  infrequently,  betrothals  and  pregnancies 
result  during  such  attacks.  Patients  show  extraordinary 
craftiness  in  this  peculiar  and  senseless  behavior.  All 
attempts  on  the  part  of  relatives  to  control  them  are  vain, 
often  irritate  the  patient,  and  give  rise  to  passionate  out- 
bursts and  even  aggressiveness. 

The  disease  picture  as  seen  in  the  individual  cases  varies 
considerably.  The  milder  the  disease  process,  the  greater 
the  opportunity  for  the  individual's  characteristics  to  enter 
into  the  symptom  picture.  Personal  peculiarities  are  par- 
ticularly apt  to  show  themselves  in  the  emotional  field. 
While  many  patients  remain  amiable,  tractable,  and  ap- 
proachable, and  are  troublesome  only  because  of  their  rest- 
lessness, others  are  extremely  disagreeable  on  account  of 
their  imperiousness,  irritability,  and  reckless  pressure  of 
activity. 


394  FORMS  OF  MENTAL  DISEASE 

Physical  Symptoms.  —  The  number  of  hours  of  sleep  is  cut 
short  by  late  retiring  and  early  rising,  but  the  actual  sleep 
is  profound.  The  appetite  is  regularly  improved,  and  the 
weight  may  increase.  The  skin  appears  healthy,  and  the 
movements  are  strong  and  elastic. 

The  course  in  this  form  is  usually  uniform.  Improve- 
ment is  very  gradual,  and  often  accompanied  by  remissions. 
The  duration  is  seldom  less  than  several  months,  and  some- 
times lasts  over  a  year.  The  disease  may,  however,  last 
for  only  a  few  days.    This  condition  often  follows  mania. 

Mania  (Tobsucht). — The  border  line  between  hypo- 
mania  and  the  less  severe  forms  of  manic  excitement  is  not 
always  sharply  defined.  The  onset  of  mania  is  almost 
always  sudden,  following  a  short  period  of  headache  or 
malaise,  although  a  few  days  of  simple  depression  may  pre- 
cede the  onset.  The  patients  rapidly  develop  great  psycho- 
motor restlessness,  with  a  pronounced  flight  of  ideas,  cloud- 
ing of  consciousness,  disorientation,  and  great  impulsiveness. 

Consciousness  is  more  or  less  clouded.  This  is  seen  in 
partial  or  complete  disorientation.  Patients  know  the  time 
and  where  they  are,  but  they  perceive  only  in  a  superficial 
way  the  events  of  the  environment.  They  mistake  those 
about  them  for  old  acquaintances.  Sometimes  they  desig- 
nate them  as  historical  personages,  as  congressmen,  public 
officials,  or  well-known  millionnaires.  Apprehension  is 
greatly  interfered  with  by  the  extraordinary  distractibility  : 
sounds  from  the  surroundings  are  caught  up  and  woven 
into  their  speech;  an  object  held  by  the  physician,  or  parts 
of  his  clothing,  attract  the  attention  and  quickly  lead  the 
thought  in  another  direction,  which  is  just  as  abruptly  left 
before  the  thought  is  half  expressed,  aiding  in  the  produc- 
tion of  a  flight  of  ideas.  Patients  understand  what  is  said 
to  them,  and  are  able  to  give  short,  correct,  and  pertinent 


MANIC-DEPRESSIVE   INSANITY  395 

answers  to  questions.  In  this  way  facts  concerning  their 
past  lives  and  occupation  can  be  obtained  by  piecemeal. 
Very  often  a  patient  shows  some  insight  into  his  disordered 
condition,  admitting  that  he  is  crazy  and  cannot  control 
himself. 

In  emotional  attitude  the  patients  are  mostly  happy  and 
exuberant.  Irritability,  on  the  other  hand,  is  very  marked. 
Trifling  affairs,  such  as  interference  or  contradictions,  may 
lead  to  outbursts  of  passion  with  profane  abuse,  assaults, 
or  destruction  of  the  clothing  or  other  objects.  The  rapid 
changes  of  the  emotions  are  still  more  characteristic.  In 
the  midst  of  joy  they  begin  to  lament  and  weep  at  the  thought 
of  home,  or  because  of  abuse  by  their  nurse.  Abrupt  changes 
to  a  condition  of  passion  and  rage  are  not  infrequent. 

In  the  'psychomotor  field  there  is  great  activity  and  excite- 
ment. Patients  cannot  sit  or  he  still;  they  run  back  and 
forth,  dance  about,  turn  handsprings,  sing,  shout,  and  prat- 
tle incessantly,  make  all  sorts  of  gestures,  tear  off  clothing, 
pull  down  the  hair,  clap  the  hands,  smear  the  person  and 
room  with  grotesque  designs,  and  ornament  themselves 
in  the  most  fantastic  manner  with  clothing  which  has  been 
torn  into  strips,  as  shown  in  Plate  11.  Everything  that  they 
can  lay  their  hands  upon,  from  watch  to  shoes,  is  taken  to 
pieces.  Bits  of  straw  and  pieces  of  stone,  glass,  and  food 
are  hoarded  to  plaster  up  a  crevice  in  the  wall  or  to  pack  a 
keyhole.  In  the  absence  of  tobacco  all  sorts  of  material 
are  used,  —  leaves  and  bits  of  bread  and  even  dried  feces. 
They  are  especially  apt  to  cram  the  nostrils  and  ears  with 
foreign  material,  and  to  carry  bits  of  glass,  nails,  stones,  and 
nutshells  in  the  mouth.  One  of  my  patients  secreted  a 
four-inch  nail  and  an  extracted  tooth  in  his  mouth  for  months. 
They  are  quarrelsome  and  domineering,  or  mischievous 
and  playful.    Because  of  great  irritability,  the  most  trivial 


396  FORMS  OF  MENTAL  DISEASE 

affairs  may  lead  to  extreme  violence  and  abuse.  Female 
patients  are  more  apt  to  show  this  tendency  than  male. 
Sexual  excitement  is  manifest  in  shameless  masturbations, 
exposure,  and  demands  for  intercourse,  by  indecent  atti- 
tudes and  insinuating  remarks. 

Some  of  these  cases  of  mania  may  show  for  a  longer  or 
shorter  period  complete  dazedness.  The  patients  then  ap- 
prehend their  environment  only  in  a  fragmentary  manner 
and  are  wholly  disorientated.  There  is  also  great  incoherence 
of  speech,  often  combined  with  pronounced  hallucinations 
and  delusions.  The  hallucinations  are  usually  transitory. 
Sometimes  faces  are  seen  on  the  wall,  shining  objects  appear 
on  the  ceiling,  and  flash-lights  are  seen  as  signals  in  the  sky. 
Noises  are  heard,  floors  creak,  locomotives  whistle,  bells 
ring,  and  poisonous  vapors  are  set  free  in  their  rooms  at 
night.  Sometimes  they  complain  of  feeling  electric  shocks. 
Delusions  are  mostly  expansive,  seldom  depressive.  They 
are  changeable  and  embellished  by  numerous  fabrications. 
Patients  claim  that  they  are  royal  personages  or  generals, 
that  they  have  supernatural  strength,  can  produce  planets, 
and  are  related  to  God,  etc.  Many  of  these  ideas  are  recog- 
nized by  the  patients  as  pure  fabrications,  are  expressed 
with  a  laugh,  and  forgotten  the  next  moment. 

Physical  Symptoms. — The  sleep  is  usually  much  disturbed, 
and  the  patients  may  go  weeks  with  almost  no  sleep.  Nu- 
trition suffers  in  spite  of  increased  appetite,  but  food  is 
taken  hurriedly  and  irregularly.  There  often  occur  attacks 
of  syncope,  and  sometimes  even  convulsive  attacks  of  a 
hysteroid  character.  The  heart's  activity  is  usually  increased 
and  the  pulse  slowed,  while  the  blood  pressure  is  dimin- 
ished. The  urine  is  found  to  show  a  striking  diminution  of 
the  phosphates,  while  calcium  and  magnesium  are  increased. 
The  quantity  of  urine  also  is  often  increased.     Pilcz  has 


Plate  11.     Self-decorated  manic  patient. 


MANIC-DEPRESSIVE'  INSANITY  397 

shown  that  both  in  the  manic  and  depressive  phases  there 
is  excreted  an  abnormal  amount  of  acetone,  diacetic  acid, 
indocan,  and  albumoses,  which,  however,  bear  no  definite 
relation  to  the  intensity  of  the  symptoms. 

Course.  —  The  height  of  the  disease  is  usually  reached  in 
the  course  of  a  week  or  two,  and  in  some  cases  within  a 
few  days.  The  intensity  of  the  symptoms  is  fairly  uniform, 
with  only  slight  fluctuations.  Occasionally  there  may 
appear  a  sorrowful  and  depressed  emotional  condition, 
with  disappearance  of  the  motor  activity,  or  even  a  tran- 
sient stupor,  indicating  a  transitory  depressive  state.  Genu- 
ine improvement  is  very  gradual;  furthermore,  for  some  time 
after  the  return  of  comparative  clearness,  the  patients  are 
apt,  under  strain,  to  show  a  flight  of  ideas  and  some  in- 
creased activity.  Even  after  apparent  complete  recovery, 
trying  conditions,  reverses  and  misfortunes,  and  more  often 
intoxication  can  cause  a  recurrence  of  the  symptoms.  The 
duration  varies  considerably,  from  a  few  weeks  and  even  days 
to  many  months,  and  sometimes  two  or  three  years.  The 
usual  duration  is  many  months.  Some  cases  extend  over 
several  years.  The  cases  with  many  delusions  and  those 
with  exacerbations  of  excitement  last  longer. 

Delirious  Mania.  —  This,  the  extreme  of  the  manic  states, 
is  characterized  by  pronounced  dreamy  clouding  of  conscious- 
ness, intense  psychomotor  activity,  great  incoherence  of  speech, 
a  marked  flight  of  ideas,  numerous  hallucinations,  and  dream- 
like delusions. 

These  cases  are  very  rare,  and  there  is  a  question  if  they 
really  belong  to  manic-depressive  insanity.  The  onset  is 
sudden,  following  a  few  days  of  indisposition,  uneasiness, 
and  insomnia.  The  patients  suddenly  develop  the  greatest 
possible  restlessness  with  many  hallucinations,  which  are 
present  in  all  of  the  sensory  fields :  they  see  beautiful  sights, 


398  FORMS  OF  MENTAL  DISEASE 

strange  faces,  and  scenes  of  torture;  hear  distant  music, 
ringing  bells,  cannonading,  and  the  roar  of  wild  animals. 
Their  food  has  a  peculiar  odor  and  taste,  and  small  objects 
crawl  on  the  skin.  They  see  fire  and  hear  the  crackling 
timbers.  Everything  is  changed.  At  the  same  time  mani- 
fold, confused,  and  dreamlike  delusions  appear,  both  of  an 
expansive  and  of  a  depressive  nature :  they  are  the  "  chosen 
ones,"  have  been  elected  Presidents,  have  wonderful  power, 
can  create  and  destroy  nations,  possess  millions ;  they  have 
lost  all  friends,  are  to  be  murdered,  must  enter  hell,  have 
been  taken  to  an  immense  height,  and  are  now  to  be  cast 
into  the  sea,  etc. 

From  the  first  the  consciousness  is  greatly  clouded,  and 
disorientation  is  almost  complete.  The  patients  are  thor- 
oughly confused  as  to  time,  place,  and  persons;  they  mis- 
take their  environment,  and  even  their  friends. 

Their  speech  is  incoherent,  abounding  in  sound  associa- 
tions, rhymes,  and  numerous  repetitions  of  single  syllables 
and  phrases,  in  which  one  can  always  detect  many  frag- 
mentary references  to  objects  in  their  environment.  At- 
tention usually  cannot  be  attracted  except  momentarily, 
when  a  fragment  of  the  desired  response  can  be  detected 
in  the  incoherent  speech.  Striking  objects,  such  as  a  penny 
dropped  on  the  floor,  will  divert  the  attention  and  the  train 
of  thought  for  a  moment. 

As  to  the  emotional  attitude,  the  patients  show  various 
changes  between  extreme  happiness  and  profound  distress, 
ecstatic  joy  and  timidity,  exuberance  and  apathy.  Irri- 
tability is  very  marked. 

In  the  psychomotor  field  the  patients  exhibit,  from  the 
beginning,  signs  of  the  most  extreme  excitement.  They 
run  about  shouting  and  singing,  disrobing,  destroying  every- 
thing within   reach,  and    they  become    recklessly  violent 


MANIC-DEPRESSIVE   INSANITY  399 

and  smear  themselves.  Occasionally  they  impulsively 
attempt  suicide.  At  one  moment  they  are  praying,  at  the 
next  cursing  with  the  vilest  language,  or  singing  an  obscene 
song;  at  one  time  they  are  insulting  in  speech  and  action, 
and  a  minute  later  are  profuse  in  apologies  and  distaste- 
fully affectionate.  They  chatter  away,  scream  and  stamp 
their  feet,  pound  the  window  or  door,  race  about  at  the 
greatest  speed,  mount  the  furniture  and  declaim  in  a  loud 
voice  with  profuse  and  exaggerated  gestures. 

Physical  Symptoms.  —  The  state  of  nutrition  suffers 
profoundly  because  of  the  small  amount  of  food  taken  and 
the  excessive  expenditure  of  energy.  Occasionally  there  is 
a  general  muscular  tremor.  Sleep  is  greatly  disturbed,  and 
at  the  height  of  the  disease  is  entirely  lacking;  the  pulse 
is  accelerated  and  the  reflexes  are  exaggerated.  Sometimes 
the  conjunctivae  are  injected,  and  the  vessels  of  the  head 
and  face  distended.  Occasionally  there  is  profuse  per- 
spiration. 

Course.  —  The  height  of  the  attack  is  quickly  reached, 
usually  within  a  few  days  or  weeks,  and  the  symptoms 
begin  to  abate  at  the  third  or  fourth  week.  Brief  intervals 
of  composure  often  occur  for  a  few  minutes  or  a  few  hours, 
during  which  the  consciousness  remains  clouded.  The 
improvement  may  be  rapid,  i.e.  over  night,  but  usually  is 
gradual.  For  some  time  the  patients,  although  clear,  usually 
retain  residuals  of  their  hallucinations,  delusions,  and  pe- 
culiarities of  conduct,  and  are  especially  inclined  to  be 
irritable  and  distrustful.  But  even  these  signs  entirely 
disappear  in  the  course  of  a  few  weeks.  There  is  rarely 
any  memory  for  the  events  of  the  acute  stage  of  the  psy- 
chosis. The  disease  may  terminate  fatally  as  the  result  of 
exhaustion,  injuries,  fat  embolism  of  the  lungs,  or  inter- 
current infections. 


400  FORMS  OF  MENTAL  DISEASE 

It  very  often  happens  that  following  a  manic  attack  the 
patients  exhibit  a  low-spirited  condition  with  more  or  less 
general  weakness,  which  sometimes  is  regarded  as  a  sort  of 
reaction,  but  which  really  represents  a  transition  into  a 
characteristic  depressed  phase.  These  patients  tire  very 
easily,  and  are  unable  to  apply  themselves  to  either  physical 
or  mental  work,  are  despondent,  worry  about  the  future, 
are  reticent,  sluggish,  and  indecisive.  These  symptoms 
gradually  disappear  with  the  increase  of  weight.  In  some 
instances,  where  the  condition  is  more  severe,  there  may 
remain  a  permanent  lack  of  judgment  and  insight,  some 
emotional  irritability,  and  also  restlessness. 

Depressive  States 

The  depressive  states  comprise  simple  retardation  and 
the  delusional  form. 

The  mildest  form  of  the  depressive  states  is  character- 
ized by  the  presence  of  simple  retardation  unaccompanied  by 
any  hallucinations  or  delusions,  and  is,  therefore,  termed 
simple  retardation. 

The  onset  is  generally  gradual,  except  in  a  few  cases 
which  follow  acute  illness  or  mental  shock.  There  appears 
gradually  a  sort  of  mental  sluggishness:  mental  processes 
become  retarded,  thought  is  difficult,  and  patients  find  diffi- 
culty in  coming  to  a  decision,  in  forming  sentences,  and  in 
finding  words  with  which  to  express  themselves.  It  is  hard 
for  them  to  follow  the  thought  in  reading  or  ordinary  con- 
versation. The  process  of  association  of  ideas  is  remarkably 
retarded;  the  patients  do  not  talk,  because  they  have  nothing 
to  say;  there  is  a  dearth  of  ideas  and  a  poverty  of  thought. 
Familiar  facts  are  no  longer  at  their  command,  and  it  is  hard 
to  remember  the  most  commonplace  things. 

In  spite  of  this  great  slowness  of  apprehension  and  thought, 


MANIC-DEPRESSIVE  INSANITY  401 

consciousness  and  orientation  are  well  retained.  Patients 
appear  dull  and  sluggish,  and  explain  that  they  really  feel 
tired  and  exhausted.  They  sit  about  as  if  benumbed,  with 
folded  hands  and  bowed  head,  exhibiting  no  initiative  and 
rarely  uttering  a  word  voluntarily.  What  is  said  is  uttered 
in  low,  inexpressive  tones.  Customary  actions,  such  as 
walking,  dressing,  and  eating,  are  performed  very  slowly, 
as  if  under  constraint.  When  started  for  a  walk,  they 
halt  at  the  doorway  or  at  the  first  turning-point,  undecided 
which  way  to  go.  Their  usual  duties  loom  before  them  as 
huge  tasks,  because  they  lack  strength  to  overcome  the  re- 
tardation, and  anything  new  appears  unsurmountable. 
Sometimes  they  become  bedridden.  Because  of  this  ex- 
treme retardation,  the  patients  rarely  commit  suicide,  al- 
though they  often  express  the  desire  to  die.  Attempts  at 
suicide  are  more  to  be  feared  when  the  retardation  has  dis- 
appeared, and  while  the  despondency  still  persists. 

In  the  emotional  attitude  there  is  a  uniform  depression. 
The  patient  sees  only  the  dark  side  of  life.  The  past  and 
the  future  are  alike,  full  of  unhappiness  and  misfortune. 
Life  has  lost  its  charm;  they  are  unsuited  to  their  environ- 
ment, are  a  failure  in  their  profession,  have  lost  religious 
faith,  and  live  from  day  to  day  in  gloomy  submission  to 
their  fate-.  Everything  is  spoiled  for  them;  they  take  no 
pleasure  in  life  and  do  not  care  to  live  longer.  They  are 
ill-humored,  gloomy,  shy,  sometimes  pettish  or  anxious, 
and  sometimes  irritable  and  sullen.  They  fear  business 
reverses  and  begin  to  economize,  even  denying  themselves 
and  their  families  the  necessaries  of  life. 

Sometimes  numerous  compulsive  ideas  appear.  Patients 
feel  compelled,  against  their  will,  to  ponder  over  certain 
things,  and  to  busy  themselves  with  depicting  unpleasant 
scenes.     Others  worry  themselves  over  the  thoughts  of  how 

2d 


402  FORMS  OF  MENTAL  DISEASE 

they  might  be  martyred  or  torn  limb  from  limb.  Even 
compulsions  to  act  arise,  such  as  to  commit  injury  or  to 
set  fire. 

Insight  is  frequently  present,  the  patients  appreciating 
that  a  change  has  come  over  them.  This  very  often  is 
characteristically  expressed  as  a  feeling  of  inadequacy.  The 
patients  say :  "  I  am  not  sick,  I  am  only  lacking  a  will  of 
my  own."  "  I  can't  pull  myself  together."  "  I  have  no 
energy,  I  can't  get  hold  of  myself."  "  I  feel  all  gone  and 
I  can't  make  up  my  mind  to  do  anything."  Sometimes  the 
recurring  sadness  is  ascribed  to  external  influences,  such  as, 
unpleasant  experiences,  changes  in  the  environment,  etc. 

The  condition  of  retardation  may,  at  some  time  during 
the  course  of  the  psychosis,  become  so  pronounced  as  to 
produce  a  condition  of  stupor.  Patients  then  lie  abed  per- 
fectly dumb,  unable  to  comprehend  their  surroundings,  or 
to  understand  even  simple  questions.  There  is  no  particular 
emotional  change  to  be  noted,  except  occasionally  when  a 
look  of  anxiety  or  perplexity  flits  across  the  countenance. 
Voluntarily,  the  patients  almost  never  speak.  If  able  to 
answer  questions,  their  responses  are  exceedingly  slow- 
They  sit  helplessly  before  their  meals,  allowing  themselves 
to  be  fed  by  spoon,  and  holding  firmly  whatever  may  be 
pressed  into  their  hands.  These  patients  are  unable  to 
care  for  themselves,  but  are  not  filthy.  This  condition  of 
stupor  tends  to  disappear  rapidly,  and  leaves  no  memory 
of  the  events  of  the  period. 

Simple  retardation  runs  a  rather  uniform  course,  with  few 
variations.  The  improvement  is  gradual,  and  the  dura- 
tion varies  from  a  few  months  to  over  a  year. 

A  second  group  of  depressive  cases  has  been  termed  the 
delusional  form,  which  is  characterized  by  the  presence  of 
varied   depreciatory   delusions,    especially   of   self-accusation 


MANIC-DEPRESSIVE  INSANITY  403 

and  of  a  hypochondriacal  nature,  in  addition  to  the  evidences 
of  retardation. 

The  onset  of  this  form  is  usually  subacute,  following  a 
period  of  indisposition,  and  occasionally  even  a  short  period 
of  exhilaration  and  buoyancy  of  spirits;  a  few  cases  appear 
after  an  acute  illness  or  mental  shock. 

The  patients  become  profoundly  despondent,  and  indulge 
in  all  sorts  of  self -accusations.  They  feel  that  they  have  been 
great  sinners,  have  neglected  their  duties  and  made  many 
enemies,  have  never  done  anything  right,  and  their  whole 
life  has  been  one  long  series  of  mistakes.  They  accuse 
themselves  of  bringing  misfortune  on  others  or  of  causing 
some  great  calamity.  They  claim  that  they  are  devoid  of 
feeling  and  sympathy  for  others.  They  feel  that  they  are 
being  watched,  fear  arrest  and  imprisonment,  they  must 
die,  are  to  be  poisoned  or  shot.  Others  hold  them  in  derision, 
laugh,  and  jeer  at  them.  Their  families  are  incriminated 
by  their  misdeeds,  and  are  suffering  imprisonment.  They 
have  lost  everything,  and  will  be  driven  into  the  street  with 
their  families,  to  wander  about  in  utter  misery. 

Hypochondriacal  delusions  are  prominent  and  are  usually 
associated  with  numerous  false  bodily  sensations:  their 
health  is  ruined  as  the  result  of  masturbation;  they  are 
succumbing  to  some  malignant  disease,  and  their  organs  are 
wasting  away;  cloudy  urine  signifies  profound  disease  of 
the  kidneys;  they  can  never  recover,  and  their  body  and 
face  are  altered.  Female  patients  complain  of  being  preg- 
nant, and  often  accuse  themselves  of  immorality  and  mas- 
turbation. 

These  various  delusions  often  become  absurd  and  fan- 
tastic. A  common  delusion  is  that  everything  about  them 
is  altered:  their  home  is  not  their  own;  their  friends  and 
relatives  have  disappeared   forever;   they  do  not  belong  to 


404  FORMS  OF  MENTAL  DISEASE 

this  world;  they  themselves  are  changed,  are  but  a  skeleton 
without  life,  they  cannot  live  and  cannot  die.  Though 
struck  on  the  head  or  pierced  in  the  heart,  they  would  still 
live  on.  Their  heart  has  ceased  to  beat ;  their  stomach  and 
intestines  are  entirely  gone ;  there  are  no  feces ;  they  are  full 
to  the  throat  with  decomposing  food;  their  skin  is  all 
dried  up ;  their  bones  are  softening,  etc. 

Hallucinations  are  occasionally  associated  with  this 
condition,  when  groans  and  moans  are  heard,  disagreeable 
odors  permeate  the  room,  terrible  apparitions  appear  at 
night,  and  fearful  scenes  are  depicted. 

The  consciousness  is  for  the  most  part  unclouded,  and  the 
patients  are  usually  oriented,  and  comprehend  correctly 
what  transpires  in  their  environment,  although  occasionally 
they  develop  some  delusional  ideas  in  reference  to  the  home 
or  institution  and  the  persons  around  them.  They  under- 
stand questions  and  answer  coherently,  but  the  content  of 
thought  and  speech  shows  a  constant  tendency  to  revert 
to  their  depressive  delusions.  Thought  is  retarded,  as  shown 
in  their  attempts  to  write  letters  or  to  solve  a  problem. 

Insight  into  the  condition  is  very  often  present,  yet  while 
admitting  recovery  from  previous  similar  attacks,  they  de- 
clare that  their  present  condition  is  so  much  worse  that  they 
can  never  recover.  Some  of  these  patients  go  to  an  insti- 
tution of  their  own  accord.  The  emotional  attitude  is  uni- 
formly one  of  depression.  The  patients  are  dejected, gloomy, 
and  perplexed,  and  lament  for  hours  in  monotonous  tones. 
They  say  little  to  those  about  them,  but  sit  staring  into  space 
and  paying  very  little  attention  to  their  environment.  It, 
however,  becomes  evident  during  the  visits  of  friends  and 
relatives  that  they  are  not  only  not  apathetic,  but  capable  of 
showing  considerable  feeling. 

Psychomotor  retardation  of  thought  and  action  is  evident 


MANIC-DEPRESSIVE   INSANITY  405 

in  their  dearth  of  ideas,  their  silence,  and  slow  and  hesitat- 
ing replies  to  questions,  their  sluggish  and  languid  move- 
ments, their  lack  of  independent  activity  and  inability  to 
apply  themselves  to  mental  work.  Some  patients  at  times 
exhibit  anxious  restlessness,  pacing  up  and  down  the  room, 
swaying  the  body  or  rocking  uneasily  in  a  chair,  picking  at 
the  clothing  or  rubbing  some  part  of  the  body.  Suicidal 
attempts  are  not  infrequent. 

Stuporous  states  may  also  develop  in  this  delusional  type 
of  depressive  cases.  The  patients  then  develop  a  condition 
of  befogged  consciousness,  in  which  almost  no  external 
impressions  are  apprehended  and  consciousness  is  domi- 
nated by  numerous  variegated  and  incoherent  delusions 
and  hallucinations.  Everything  appears  changed  in  the 
most  fantastic  manner;  the  whole  world  is  being  consumed 
by  fire  or  congealed  into  ice.  They  themselves  are  removed 
from  everybody,  have  been  taken  up  into  a  cloud  and 
carried  off  to  the  farthest  point  of  the  universe,  and  left 
there  alone.  They  are  to  be  shoved  off  into  space,  where  they 
will  keep  falling  forever,  or  they  are  crowded  into  a  narrow 
grave  from  which  they  can  never  escape.  The  walls  of  the 
room  are  closing  in  upon  them,  and  passing  troops  have 
arrived  to  attend  their  execution.  Crowds  jeer  at  them; 
they  are  made  to  wear  a  crown  of  thorns,  or  are  turned  loose 
to  run  naked  in  the  street.  Everything  about  them  has  a 
most  mysterious  aspect;  they  are  in  the  midst  of  historical 
personages,  and  are  made  to  do  penance  for  the  whole  world. 
They  have  been  transformed  in  a  most  horrible  manner, 
are  of  a  different  sex,  are  swollen  to  the  size  of  a  cask,  have 
two  heads,  the  body  of  a  serpent,  and  the  feet  of  an  elephant. 
While  in  this  dreamy  state  their  retardation  is  shown  by 
their  inability  to  speak,  to  feed  themselves,  or  to  care  for 
themselves  in  any  way.    They  do  not  show  active  feelings, 


406  FORMS  OF  MENTAL  DISEASE 

but  lie  stupidly  in  bed,  are  inaccessible  and  indifferent. 
An  occasional  anxious  expression,  the  resistance  to  passive 
movements,  peculiar  postures,  and  unexpected,  impulsive 
attempts  at  suicide  betray  their  anxiety  and  fear.  Some- 
times a  few  words  or  sentences  are  uttered  very  slowly 
and  in  low  tones.  These  stuporous  states  disappear  gradu- 
ally, but  even  after  consciousness  has  become  clear,  a  few 
hallucinations  and  delusions  usually  persist  for  some 
time. 

There  are  a  few  cases  which  present  coherent  delusions 
of  persecution  accompanied  by  many  hallucinations  with 
clear  consciousness.  The  hallucinations  play  a  rather  im- 
portant part  and  persist  for  a  long  time,  reminding  one 
very  much  of  acute  alcoholic  hallucinosis,  save  for  the 
psychomotor  retardation. 

Physical  Symptoms.  —  The  patients  complain  of  numb- 
ness in  the  head,  ringing  in  the  ears,  dizziness,  palpitation, 
chilliness  in  the  neck,  heaviness  in  the  limbs,  and  of  a  feeling 
as  if  there  was  a  weight  upon  the  chest.  The  appetite  is 
poor,  the  tongue  coated,  and  the  bowels  constipated.  There 
is  usually  a  strong  aversion  to  food,  and  it  often  requires 
considerable  urging  to  administer  sufficient  nourishment. 
The  sleep  is  much  broken  and  disturbed  by  anxious  dreams. 
The  facial  expression  and  the  general  attitude  are  sleepy 
and  languid,  the  speech  low,  the  eyes  lustreless,  the  skin 
sallow  and  without  its  accustomed  firmness.  The  body 
weight  always  sinks.  Respiration  and  cardiac  activity 
are  weakened  and  slower,  and  blood  pressure  is  increased, 
while  the  pulse  is  slow.  The  quantity  of  urine  is  dimin- 
ished as  well  as  the  excretion  of  urea,  phosphoric  acid,  and 
magnesia.  The  height  of  the  disturbance  is  reached  in  a 
few  weeks  and  runs  a  shorter  course  than  the  manic 
states. 


MANIC-DEPRESSIVE  INSANITY  407 

Mixed  States1 

In  these  states  there  occur  simultaneously  varying 
combinations  of  some  of  the  fundamental  symptoms  character- 
istic of  both  the  manic  and  depressive  phases  of  the  disease. 

The  mixed  states  are  most  clearly  seen  during  the  transi- 
tion periods  when  patients  pass  from  a  manic  to  a  depressive 
phase  or  vice  versa.  At  these  times  all  the  symptoms  of  one 
phase  do  not  disappear  simultaneously,  so  that  symptoms 
of  the  depressive  phase  develop  before  all  of  the  symptoms 
of  the  manic  disappear.  For  instance,  the  characteristic 
manic  flight  of  ideas  may  have  given  way  to  typical  retarda- 
tion of  thought,  while  there  still  remains  emotional  elation 
and  pressure  of  activity.  A  few  days  farther  along  in  this 
transition  period,  we  find  that  there  still  is  some  elation, 
but  retardation  of  activity  has  also  developed.  Later  still, 
and  the  elation  has  given  way  to  depression,  and  we  have  the 
typical  picture  of  the  depressive  phase.  In  another  case 
during  this  transition  period,  the  emotional  elation  may  be 
the  first  symptom  to  subside  and  pass  into  despondency, 
while  there  still  remain  pressure  of  activity  and  flight  of 
ideas.  In  a  few  days  the  flight  of  ideas  also  has  gone  over 
into  retardation  of  thought,  while  there  is  still  some  pressure 
of  activity.  Farther  along,  we  find  the  pressure  of  activity 
replaced  by  retardation  and  the  typical  depressive  picture. 
All  together  there  have  thus  far  been  recognized  six  chief 
types  of  mixed  states. 

(1)  Irascible  mania,  in  which  a  depressed  emotional  state 
replaces  the  usual  elation.  These  are  the  cases  of  pronounced 
manic  excitement  in  which  the  patients  exhibit  a  more  or 
less  constant  irritability;  they  heap  abuse  upon  the  environ- 

1  Weygandt,  Ueber  die  Mischzustaende  des  manisch-depressiven  Irre- 
seins.     Habilitationsschrift,  1899. 


410  FORMS  OF  MENTAL  DISEASE 

transient  periods  of  genuine  mania  with  flight  of  ideas  and 
pronounced  pressure  of  activity. 

(4)  Manic  stupor  is  the  depressive  state  in  which  emo- 
tional elation  takes  the  place  of  the  usual  despondency. 
The  patients  are  quite  unapproachable;  they  do  not  bother 
themselves  about  their  environment,  will  not  answer  ques- 
tions, laugh  without  apparent  cause,  he  quietly  in  bed, 
sometimes  all  rolled  up  in  the  clothing,  or  dress  them  up  in 
a  fantastic  manner,  but  all  of  this  is  done  without  evidence 
of  restlessness  or  emotional  agitation.  Sometimes  a  few 
changeable  delusions  are  expressed.  They  are  usually 
well  oriented.  Occasionally  catalepsy  is  present.  In  the 
midst  of  this  stupor  the  patients  suddenly  develop  great 
activity,  rush  about,  disrobe,  tear  their  clothing,  destroy 
furniture,  smear  their  food,  sing  and  talk  loudly  and  freely, 
often  making  bright  and  striking  remarks,  and  then  after 
a  few  hours  as  quickly  return  to  the  previous  state.  At 
other  times  one  finds  them  quiet,  perfectly  clear  and  intelli- 
gent in  conversation,  but  this  is  only  for  short  periods. 
Many  patients  pace  about  in  measured  steps,  never  speak 
except  to  make  an  occasional  witty  remark,  or  rub  up  against 
the  doctor  in  an  erotic  manner,  and  laugh.  These  patients 
often  have  a  good  memory  for  what  occurs,  but  they  are 
wholly  unable  to  explain  their  peculiar  conduct.  In  some 
cases  the  facial  expression  is  fixed  and  staring,  in  others  it 
is  more  cheerful,  happy,  and  amorous. 

Manic  stupor  often  develops  for  a  short  time  in  a  pro- 
nounced manic  state,  but  it  more  frequently  represents  a 
transition  state  between  a  depressive  stupor  and  a  manic 
state. 

(5)  Depression  with  a  Flight  of  Ideas. — These  depressive 
cases  are  easily  aroused  when  they  can  show  a  facility  of 
thought.    They  read  a  good  deal,  show  interest  in  and  com- 


MANIC-DEPRESSIVE  INSANITY  411 

prehend  their  environment,  and,  indeed,  even  evince  some 
curiosity,  in  spite  of  the  fact  that  they  are  retarded  in  their 
general  attitude,  are  almost  mute,  and  are  despondent. 
These  patients  tell  us  as  soon  as  they  begin  to  talk  again 
that  they  could  not  control  their  thoughts,  that  a  whole 
host  of  things  would  come  into  their  minds  which  they  had 
never  thought  of  before.  It  seems,  therefore,  that  there 
really  exists  a  flight  of  ideas  which,  however,  is  not  apparent 
to  others  because  of  the  retardation  of  the  movements  of 
articulation.  Some  of  these  patients  cannot  express  them- 
selves orally,  but  can  write,  and  often  astonish  one  with 
their  numerous  productions,  containing  delusional  ideas  of 
persecution  and  fear. 

(6)  Finally  there  is  the  depressive  state  with  flight  of 
ideas  and  emotional  elation.  These  patients  are  happy, 
sometimes  somewhat  irritable,  are  distractible,  prone  to 
witty  remarks,  and  are  easily  aroused  during  conversation 
to  a  flight  of  ideas  and  at  times  even  sound  associations, 
but  in  general  their  demeanor  is  quiet.  They  lie  quietly 
in  bed,  and  now  and  then  interpolate  a  remark  or  laugh 
loudly.  Nevertheless  there  seems  to  exist  an  inner  tension, 
because  the  patients  can  suddenly  become  very  violent. 

The  mixed  states  occur  most  frequently  in  the  transition 
periods  from  manic  to  depressive  states  and  vice  versa. 
Indeed,  it  is  only  by  the  history  of  their  development  and  their 
transition  into  the  well-known  phases  of  the  disease  that 
we  are  able  to  recognize  them  as  mixed  phases  and  as  a 
type  of  manic-depressive  insanity.  This  observation  is  of 
especial  importance  in  those  cases  in  which  mixed  states 
almost  wholly  replace  the  typical  manic  and  depressive 
phases.  In  such  cases  the  recognition  of  the  disease, 
particularly  in  the  first  attack,  is  extremely  difficult,  if 
not  impossible. 


412  FORMS  OF  MENTAL  DISEASE 

Course.  —  The  course  of  manic-depressive  insanity  is 
marked  by  a  recurrence  of  attacks  separated  by  lucid  inter- 
vals. With  but  very  few  exceptions,  attacks  recur  throughout 
the  life  of  the  individual,  appearing  with  greater  frequency 
between  the  ages  of  eighteen  to  thirty  and  forty  to  fifty. 
In  five  per  cent,  of  cases  the  attacks  from  the  first  pass  di- 
rectly from  one  phase  into  another,  sometimes  with  such 
regularity  that  the  name  "  alternating  insanity  "  has  been  ap- 
plied to  them,  or  if  short  intervals  of  lucidity  have  intervened, 
"  circular  insanity."  If  only  one  or  two  attacks  occur  during 
the  life  of  an  individual,  the  separate  attacks  are  in  no 
way  essentially  different  from  those  recurring  frequently. 
It  seldom  happens  that  all  are  of  the  same  type ;  at  some  time 
or  other  a  depressive  attack  is  sure  to  appear.  On  the  other 
hand,  one  patient  during  life  may  suffer  from  all  possible 
forms,  from  hypomania  to  profound  stupor. 

The  first  attack  in  sixty  per  cent,  of  the  cases  is  depressive. 
This  is  especially  true  in  women,  and  when  the  disease  de- 
velops early  in  life.  The  first  depressive  attack  usually 
runs  a  mild  course,  and  in  about  fifty  per  cent,  of  the  cases 
is  followed  immediately  by  a  lucid  interval.  In  the  other 
fifty  per  cent,  of  the  cases  it  is  immediately  followed  by  a 
manic  attack,  which  in  turn  is  followed  by  a  lucid  interval. 
A  first  manic  attack  is  almost  always  followed  by  a  lucid 
interval,  seldom  by  a  depressive  attack.  If  the  first  attack  is 
manic,  the  majority  of  the  succeeding  attacks  are  manic. 
Similarly,  several  depressive  attacks  may  recur  before  a 
manic  attack  appears;  in  other  words,  the  occurrence  of 
several  attacks  of  one  type  to  the  exclusion  of  other  types 
indicates  that  the  greater  number  of  attacks  throughout 
life  will  be  of  the  same  character.  Later  in  the  course  of 
the  disease  there  may  be  a  regular  alternation  between 
manic  and  depressive  attacks.    After  a  long  duration  of 


MANIC-DEPRESSIVE  INSANITY  413 

the  disease  there  is  more  apt  to  be  a  regular  alternation 
from  one  type  to  the  other,  if  the  early  attacks  have 
been  mostly  of  one  type.  The  mixed  forms  usually  do 
not  appear  until  after  two  or  more  manic  or  depressive 
attacks. 

The  duration  of  the  individual  attack  may  vary  from  a 
few  days  to  five  years,  but  the  usual  duration  is  from  six 
to  twelve  months.  The  depressive  attacks  average  longer. 
The  first  attacks  rarely  last  longer  than  a  few  months.  In 
the  circular  type  of  the  disease  it  has  been  observed  that 
hypomania  usually  alternates  with  simple  retardation, 
while  severe  manic  states  are  followed  by  deep  stupor,  and 
again,  when  delusions  and  hallucinations  occur  in  the  manic 
states,  they  are  usually  also  present  in  the  depressive 
states. 

The  lucid  intervals  vary  considerably  in  length,  from  a 
few  days  or  weeks  to  many  years,  and  stand  in  no  definite 
relation  to  the  duration  of  the  attacks.  They  are  apt, 
however,  to  be  longer  at  the  beginning  and  shorter  as  the 
attacks  recur,  until  finally  they  may  disappear  altogether, 
the  attacks  then  passing  directly  from  one  into  another. 
At  the  beginning  of  the  disease  the  intervals  are  usually 
of  at  least  one  or  more  years'  duration.  Sometimes  the 
intervals  are  of  such  a  definite  duration  that  the  patients 
know  just  when  to  expect  the  attacks.  The  intervals  tend 
to  become  shorter  during  the  climacterium  and  to  lengthen 
out  again  later.  Sometimes,  especially  in  young  females, 
the  disease  begins  with  a  series  of  several  short  attacks  with 
brief  intervals,  which  are  then  followed  by  a  prolonged  in- 
terval of  several  years.  In  the  small  group  of  cases  in  which 
from  the  beginning  the  attacks  succeed  each  other  without 
lucid  intervals,  the  type  of  the  attack  is  usually  light,  mostly 
hypomania  and  simple  retardation.     Sometimes,  even  after 


414  FORMS  OF  MENTAL  DISEASE 

a  long  series  of  such  recurring  attacks,  there  may  appear  a 
long  lucid  interval. 

During  the  intervals  the  patients  are  perfectly  lucid, 
except  in  a  few  cases  where  the  attacks  are  long,  frequent, 
and  severe.  They  are  able  to  reenter  the  family,  to  employ 
themselves  profitably,  and  to  return  to  their  profession. 
The  few  who  do  not  thoroughly  recover  are  also  usually 
able  to  return  home,  but  are  apt  to  show  some  restraint, 
lack  of  independence,  a  tendency  to  be  morose,  an  unusual 
susceptibility  to  fatigue,  some  sleepiness,  and  a  diminished 
capacity  for  work,  or  they  may  be  irritable,  quarrelsome, 
markedly  egotistical,  or  unstable  and  easily  excitable. 
During  the  interval  some  of  the  patients  fail  to  show  a 
thorough  appreciation  of  their  disease.  They  will  admit 
that  they  have  been  "  excited  and  nervous,"  but  attribute 
it  to  some  family  trouble  or  confinement. 

It  very  often  happens  that  during  the  intervals  the  pa- 
tients may  suddenly  develop  short  periods  of  moderate 
exhilaration,  flightiness,  irritability,  and  unusual  activity, 
or  on  the  other  hand,  they  may  be  unnaturally  apprehensive, 
suspicious,  despondent,  inactive,  and  indifferent.  These 
symptoms  disappear  abruptly,  and  without  the  history  of 
other  attacks  might  not  be  recognized  as  disease  symp- 
toms. 

The  transition  from  a  manic  to  a  depressive  phase,  and 
vice  versa,  is  usually  gradual,  though  it  may  be  sudden, 
often  occurring  during  the  night.  In  this  transition  the 
stages  of  alteration  are  usually  quite  perceptible.  At  first 
the  countenance  of  the  depressed  patient  becomes  more 
illuminated  and  the  eyes  appear  brighter  and  the  skin  firmer 
and  more  elastic.  The  patient  is  more  affable,  shows  more 
interest  in  the  surroundings,  and  expresses  a  desire  for  free- 
dom.    His  activity,  at  first  increasing  slowly,  now  becomes 


MANIC-DEPRESSIVE  INSANITY  415 

prominent;  he  is  busy  all  the  time,  is  happy,  never  felt 
better  in  his  life,  and  everything  pleases.  From  this  time 
the  manic  state  becomes  quite  evident.  The  manic  patient 
at  first  gradually  loses  weight,  the  pressure  of  activity  abates, 
he  is  calmer  and  more  in  earnest,  his  many  schemes  recede 
to  the  background  and  then  entirely  disappear.  Soon  his 
movements  become  languid,  he  himself  is  seclusive,  talks 
less,  only  occasionally  mentioning  his  ill-feelings  and  mis- 
fortunes. His  countenance  loses  its  freshness,  and  at  last 
we  have  a  typical  depressive  state. 

Diagnosis.  —  There  is  usually  little  difficulty  in  recog- 
nizing the  psychosis,  where  there  has  been  a  previous  at- 
tack; yet  the  occurrence  of  more  than  one  attack  is  by  no 
means  pathognomic  of  manic-depressive  insanity,  as  it 
may  happen  in  dementia  prsecox,  especially  in  the  catatonic 
form,  in  paresis,  melancholia,  and  in  amentia. 

It  is  difficult  to  distinguish  between  the  mildest  forms 
of  manic-depressive  insanity  and  certain  morbid  personal 
peculiarities  which  manifest  themselves  chiefly  as  a  more 
or  less  regular  vacillation  of  the  emotional  state.  The  manic- 
depressive  periods  of  ill-humor  on  the  one  hand,  and  of 
impetuous  exhilaration  on  the  other,  are  sometimes  mis- 
taken as  simple  whims  and  ascribed  to  all  sorts  of  deleterious 
influences,  or  they  are  apt  to  be  designated  as  hysteria, 
neurasthenia,  and  hypochondriasis,  since  it  is  only  in  the 
depressive  states  that  the  patients  are  considered  ill.  These 
same  patients  themselves,  however,  often  have  insight  into 
their  periods  of  excitement  and  dread  their  approach.  Usu- 
ally the  true  nature  of  the  disease  is  disclosed  by  the  transi- 
tion from  one  phase  to  another,  and  by  the  periodic  recurrence 
of  different  phases.  The  simple  lack  of  decision —  the  inabil- 
ity of  the  depressive  patients  to  come  to  a  conclusion  —  is  so 
characteristic  that  it  alone  often  suffices  in  making  the  diag- 


416  FORMS  OF  MENTAL  DISEASE 

nosis.  These  border-line  cases  are  numerous,  and  are  often 
encountered  in  sanitaria. 

In  the  mild  forms  of  the  manic  states,  when  one  sees  the 
patient  in  the  first  attack  and  is  without  a  history  of  the 
patient's  life,  it  is  often  difficult  to  distinguish  the  patients 
from  some  normal  individuals.  The  distinction  depends 
chiefly  upon  the  fact  that  the  increased  busyness  and  activ- 
ity is  not  uniform,  but  shows  variations.  In  the  forms  of 
constitutional  mania  there  are  also  noticeable  aggravations 
of  the  condition  and  regular  transitions  into  opposite  moods. 
Such  patients,  because  of  their  frequent  conflicts  with  their 
environment  and  the  law,  are  usually  considered  swindlers 
and  vagabonds,  or  are  regarded  as  morally  insane.  In  ad- 
dition to  the  vacillations,  the  clinical  picture  also  shows 
an  attitude  of  overconfidence,  an  irritability,  a  lack  of  plan 
in  their  excessive  busyness,  an  excessive  emotional  irritability, 
and  a  lack  of  criminal  tendencies. 

The  differentiation  of  the  disease  from  the  exhaustion 
psychoses  and  from  the  excited  stages  of  the  catatonic  and 
hebephrenic  forms  of  dementia  prsecox  will  be  found  fully 
detailed  in  the  differential  diagnosis  of  those  diseases. 

The  manic  forms  are  differentiated  from  hysterical  excite- 
ment by  the  presence  of  the  flight  of  ideas,  pressure  of  activity, 
the  exuberant  emotional  state,  and  the  great  distracti- 
bility.  The  hysterical  excitement  comes  in  the  form  of 
brief  separate  attacks  with  definite  outbursts  of  temper. 
Hysterical  excitement  usually  subsides  quickly  and  com- 
pletely after  a  very  short  duration. 

It  is  more  difficult  to  distinguish  simple  retardation  from 
the  initial  period  of  depression  in  dementia  prcecox.  In  the 
manic-depressive  patients  the  psychomotor  retardation, 
with  slowness  of  movement,  low  tone  of  voice,  difficulty 
of  thought  with  sparsity  of  ideas,  slowness  of  application 


MANIC-DEPRESSIVE  INSANITY  417 

of  attention,  and  slight  clouding  of  consciousness,  stands  out 
in  contrast  to  the  absence  of  retardation,  freedom  of  move- 
ments and  thought,  and  to  the  clearness  of  consciousness 
in  dementia  prsecox.  Rapid  appearance  of  senseless  de- 
lusions and  numerous  hallucinations  without  clouding  of 
consciousness  speak  for  dementia  praecox. 

The  differentiation  of  the  depressive  states  from  dementia 
paralytica  and  melancholia  have  been  discussed  under  these 
psychoses. 

Acquired  neurasthenia  is  sufficiently  differentiated  from 
the  depressed  forms  under  that  disease. 

The  unproductive  mania  is  often  mistaken  for  imbe- 
cility with  excitement,  but  can  be  distinguished  by  the  evi- 
dences of  flight  of  ideas  and  the  manic  demeanor  of  the 
patients  with  only  moderate  restlessness. 

Manic  stupor  sometimes  must  be  differentiated  from 
catatonia.  If,  in  manic  stupor,  the  patients  struggle,  the 
cause  for  it  lies  in  the  irritable,  fretful  disposition  which 
almost  always  leads  to  abuse  and  violence.  Again,  the 
patients  pay  more  attention  to  their  environment,  and  are 
influenced  in  their  actions  by  circumstances,  in  contradis- 
tinction to  the  stupid  or  wilful  indifference  of  the  catatonic. 
Furthermore,  the  manic-stuporous  patient  displays  a  pov- 
erty of  thought  and  not  a  stereotyped  and  senseless  speech 
production.  The  movements  of  the  catatonic  are  apt  to 
be  planless,  impulsive,  and  with  a  uniform  pressure  of  move- 
ment, while  in  stuporous  mania  they  are  purposeful,  play- 
ful, and  adapted  to  the  environment. 

Prognosis.  —  The  prognosis  of  the  disease  is  unfavorable 
in  view  of  the  certainty  of  recurrence  of  the  attacks  through- 
out the  life  of  the  individual.  It  is  favorable  for  recovery 
from  the  individual  attacks,  except  in  five  per  cent,  of  cases, 
which  from  the  onset  pass  directly  from  one  attack  into  an- 

2b 


418  FORMS  OF  MENTAL  DISEASE 

other.  While,  with  this  exception,  there  are  almost  certain 
to  be  other  attacks  and  recoveries,  the  frequency  of  their 
recurrence  and  the  duration  of  the  lucid  intervals  is  wholly 
uncertain.  At  present  we  have  no  means  of  judging  just 
what  the  future  course  will  be.  In  general  it  may  be  said, 
however,  that  it  is  safe  to  predict  frequent  recurrence  of 
attacks  with  short  intervals  where  the  psychosis  manifests 
itself  early  and  without  external  cause.  On  the  other  hand, 
if  the  first  attack  occurs  late  and  following  some  external 
cause,  such  as  childbirth,  there  probably  will  be  but  few 
attacks.  If  pronounced  mixed  states  predominate,  the 
disease  will  probably  be  more  severe.  If  the  onset  is  pre- 
vious to  the  period  of  involution,  one  should  expect  a  recur- 
rence during  the  climacterium. 

Mental  deterioration  occurs  in  only  a  few  cases,  where 
the  attacks  appear  during  the  period  of  development  and  are 
long,  frequent,  and  severe.  Even  these  patients  in  the 
intervals  are  conscious,  well  oriented,  and  retain  a  very 
good  memory.  They  simply  show  some  indifference,  irri- 
tability, an  increased  susceptibility  to  alcohol,  and  slight 
deficiency  in  judgment.  There  are  a  few  cases  that  have 
very  long  manic  attacks,  lasting  even  ten  years  and  more, 
which  have  been  designated  chronic  mania.  This  con- 
dition is  not  one  of  dementia,  but  one  in  which  there  are 
incomplete  remissions.  If  observed  carefully,  these  cases 
usually  present  not  only  manic  states  of  varying  intensity, 
but  also  evidences  of  depressive  and  mixed  states.  Further- 
more, it  is  usually  found  that  even  in  the  lucid  intervals  the 
patients  have  always  been  somewhat  unstable,  freakish,  irri- 
table, or  have  been  schemers  and  incapable  of  any  consistent 
and  productive  employment.  These  cases  are  better  termed 
constitutional  mania. 

There  is  a  corresponding  series  of  transitions  from  the 


MANIC-DEPRESSIVE  INSANITY  419 

depressive  states.  There  are  manic  cases  which  in  the  inter- 
vals are  shy,  low  spirited,  and  slow  to  make  up  their  minds. 
This  defective  constitution  is  more  characteristic  in  those 
individuals  who  suffer  from  periodic  depressive  states. 
Finally  there  are  cases  in  which  the  separate  attacks  of 
periodical  ill-humor  present  themselves  without  sharp 
differentiation,  and  are  simple  aggravations  of  a  constitu- 
tional depression.  Arteriosclerosis,  or  marked  senile  changes, 
developing  during  the  course  of  manic-depressive  insanity, 
usually  lead  to  states  of  dementia  which  obliterate  the  origi- 
nal mental  picture. 

Treatment.  —  The  disease,  being  deeply  rooted  in  the  per- 
sonality of  the  individual,  offers  little  chance  to  eradicate 
the  underlying  causes.  Individuals  who  seem  to  be  pre- 
disposed to  the  disease  certainly  derive  benefit  from  leading 
a  careful  life  under  favorable  conditions  and  abstaining 
absolutely  from  the  use  of  alcohol.  Such  persons  should 
not  marry. 

Individuals  suffering  from  frequently  and  regularly  re- 
curring attacks  can  sometimes  ward  off  an  approaching 
attack  by  the  use  of  large  doses  of  the  bromides,  even  up  to 
three  hundred  and  sixty  grains  a  day  for  a  few  days  before 
the  anticipated  attack.  Atropia,  hypodermically,  or  bella- 
donna in  the  form  of  the  extract  in  full  doses,  is  highly  recom- 
mended for  the  same  purpose.  In  those  cases  in  which  the 
attacks  tend  to  develop  during  pregnancy  or  puerperium, 
artificial  abortion  has  occasionally  been  performed  for  the 
purpose  of  either  warding  off  the  attack  or  cutting  it  short. 
Kraepelin  himself  has  not  derived  much  benefit  from  this 
procedure,  but  finds  that,  in  spite  of  abortion,  the  disease 
recurs  and  runs  its  regular  course.  In  all  such  cases  meas- 
ures should  be  adopted  for  the  prevention  of  pregnancy. 
Individuals  who  have  already  suffered  from  an  attack  of 


420  FORMS  OF  MENTAL  DISEASE 

the  disease  should  be  compelled  to  lead  a  quiet  life,  free 
from  irritating  influences.  The  susceptibility  to  alcohol  is 
increased,  hence  its  use  should  be  most  scrupulously  avoided. 

In  the  treatment  of  the  patient  during  the  manic  attacks, 
the  first  essential  is  the  removal  of  all  forms  of  external 
excitation.  Except  in  the  mild  cases,  it  is  unsatisfactory 
to  attempt  to  care  for  the  patient  at  home,  and  even  the 
milder  forms  run  a  more  moderate  course  under  the  influ- 
ence of  a  quiet  and  well-regulated  hospital  or  sanitarium 
environment  than  at  home.  Unrestrained  activity  tends  to 
increase  the  excitement ;  therefore  the  pressure  of  activity 
should  be  limited  as  much  as  possible.  One  of  the  best 
means  of  accomplishing  this  is  confinement  in  bed.  Bed 
treatment  is  especially  indicated  in  anemic  and  debilitated 
cases. 

In  severe  excitement  prolonged  warm  baths  (see  p.  140), 
used  in  connection  with  the  bed  treatment,  give  the  most 
satisfactory  results.  The  patients  should  alternate  from 
the  bath  to  the  bed ;  i.e.  when  the  excitement  subsides  in  the 
bath,  he  can  be  returned  to  the  bed  until  it  reappears.  It 
may  be  necessary  in  order  to  first  introduce  the  patient  to 
the  bath  to  give  a  preliminary  dose  of  hyoscin  hydrobro- 
mate  (-^jro  t°  wo  grain)-  The  prolonged  warm  bath  properly 
applied  will  often  relieve  the  greatest  excitement,  and  usually 
renders  medicinal  treatment  unnecessary.  If  the  bath  is 
not  available,  the  use  of  hyoscin  hydrobromate  hypoder- 
mically,  or  by  mouth,  is  the  best  remedy  for  subduing  the 
intense  psychomotor  activity.  Scopolamin  hydrobromate 
("2iro  t°  ^0  grain)  or  paraldehyde  may  be  substituted  for  the 
hyoscin.  As  the  excitement  permanently  subsides,  con- 
finement in  bed  can  be  gradually  relaxed  and  the  patient 
given  an  opportunity  to  exercise  in  the  open.  In  very 
extreme  excitement  with  impending  collapse  the  adminis- 


MANIC-DEPRESSIVE   INSANITY  421 

tration  of  whiskey  or  brandy  or  camphor  is  necessary,  and 
in  the  case  of  coexisting  cardiac  weakness,  digitalis  or 
caffein  should  be  added.  The  general  management  of  the 
patient  is  usually  a  veiy  important  adjuvant  in  controlling 
the  excitement.  This  requires  the  greatest  amount  of  tact 
and  patience  on  the  part  of  the  nurse;  gentle  friendliness 
at  suitable  moments  sometimes  renders  what  appears  to 
be  a  most  dangerous  patient  quite  tractable.  The  nurse 
must  exercise  self-control,  be  free  from  all  prejudice,  avoid 
the  use  of  discipline,  and  above  all  be  frank  and  truthful. 

The  nutrition  of  the  patients  demands  special  attention. 
An  abundance  of  nutritious  and  easily  digested  food  should 
be  given  the  patients  at  regular  intervals.  They  should 
not  be  allowed  to  gulp  their  food,  and  hence  it  usually  re- 
quires the  constant  attendance  of  the  nurse  at  meal-time. 
Because  of  the  great  restlessness,  it  often  requires  consider- 
able patience  to  get  an  excited  patient  to  take  sufficient 
nourishment.  In  severe  cases  the  patients  should  be  weighed 
frequently  in  order  to  ascertain  if  the  body  weight  is  falling 
off,  and,  where  necessary,  artificial  feeding  by  stomach  or 
nasal  tube  can  be  employed. 

It  is  very  often  a  difficult  matter  to  determine  just  when 
manic  patients  have  recovered  sufficiently  to  be  discharged 
from  treatment.  Because  of  their  great  importunity  and 
impatience  to  be  set  free,  there  is  a  tendency  to  discharge 
them  while  some  symptoms  still  remain.  One  of  the  dangers 
in  premature  release  is  the  tendency  to  alcoholic  indulgence, 
which  regularly  leads  to  a  recurrence  of  the  symptoms. 
The  safest  guide  in  deciding  this  question  may  be  found 
in  the  body  weight,  which  should  have  returned  to  normal. 

In  the  depressed  states  the  patients  should  at  once  be 
given  the  benefit  of  the  rest  treatment  with  confinement  in 
bed  and  ample  feeding.    Except  in  debilitated  and  anemic 


422  FORMS  OF   MENTAL  DISEASE 

cases,  the  patient  should  be  permitted  to  leave  the  bed  for 
a  short  period  during  the  day  to  take  exercise  in  the  open. 
If  this  is  not  feasible,  massage  should  be  administered. 
The  rest  treatment  taken  in  the  open  on  a  shielded  but 
sunny  porch  should  always  be  tried  in  preference  to  indoor 
confinement.  If  there  is  great  agitation,  opium  in  increas- 
ing doses  (see  p.  362)  is  often  given  with  benefit. 

The  insomnia  should  be  controlled,  if  possible,  by  the 
aid  of  the  various  physical  measures,  such  as,  hot  baths  at 
night,  hot  liquid  nourishment  upon  retiring,  gentle  massage, 
etc.  Failing  with  these,  one  may  employ  on  alternate  days 
and  for  short  periods  trional  15  grains,  veronal  7 J  grains, 
or  paraldehyde  1  to  2  drachms.  During  prolonged  periods 
of  administration,  these  hypnotics  should  be  varied. 

The  nutrition  also  demands  careful  attention,  for  which 
purpose  the  patient  should  be  frequently  weighed.  The 
food  should  be  carefully  selected  and  easily  digestible.  Ab- 
stinence from  food  often  requires  artificial  feeding  by  nasal 
or  stomach  tube.  The  relief  of  constipation,  which  often 
exists,  usually  improves  the  appetite. 

The  patient  must  be  relieved  from  all  forms  of  excitation, 
and  visits  from  relatives,  long  conversations,  letter-writing, 
etc.,  should  be  avoided.  Rational  conversation  and  encour- 
agement is  helpful,  except  at  the  height  of  the  disease,  when 
it  sometimes  seems  to  be  aggravating.  In  the  lighter  cases 
hypnotic  suggestion  has  been  used  to  great  advantage  in 
relieving  the  insomnia,  despondency,  and  disagreeable  so- 
matic sensations.  The  greatest  care  must  be  exercised  to 
prevent  suicidal  attempts,  which  are  often  to  be  most  guarded 
against  at  times  when  the  patients,  though  still  convalescing, 
believe  themselves  recovered,  and  also  in  the  transition 
periods  between  attacks. 


X.   PARANOIA1 

Paranoia  is  a  chronic  progressive  psychosis  occurring 
mostly  in  early  adult  life,  characterized  by  the  gradual  develop- 
ment of  a  stable  progressive  system  of  delusions,  without 
marked  mental  deterioration,  clouding  of  consciousness,  or 
disorder  of  thought,  will,  or  conduct. 

Etiology.  —  The  disease  is  uncommon,  constituting  only 
one  to  four  per  cent,  of  the  cases  admitted  to  insane  hos- 
pitals. Men  are  more  often  afflicted  than  women.  The 
disease  begins  between  the  ages  of  twenty-five  and  forty.  It 
develops  on  a  defective  constitutional  basis,  either  con- 
genital or  acquired,  defective  heredity  existing  in  a  very 
large  percentage  of  the  cases.  Peculiar  traits  and  eccen- 
tricities may  be  recognized  early  in  life,  the  patients  being 
moody,  dreamy,  or  seclusive.  Some  show  perverted  sexual 
instincts,  or  a  marked  aptitude  for  study  or  mental  activity 
in  special,  limited  fields.  Some  have  been  abnormally  bright ; 
others  have  always  been  flighty,  entering  into  many  projects 
which  they  were  unable  to  pursue  successfully;  many  show 
stigmata  of  degeneration.  Exciting  causes  occasionally 
form  the  starting-point  of  the  psychosis,  such  as  an  acute 
illness,  excessive  mental  stress,  shock,  business  reverses, 
deprivation,  and  disappointment. 

1  Snell,  Allgem.  Zeitschr.  f .  Psy.,  XXII,  368 ;  Griesinger,  Archiv.  f.  Psy., 
I,  148;  Sander,  ibid.,  387;  Westphal,  Allgem.  Zeitschr.  f.  Psy.,  XXXIV, 
252;  Mercklin,  Studien  liber  primure  Verruckheit,  1879;  Amadie  e 
Tonnini,  Archivio  italiano  per  le  malattie  nervose,  1884,  1,  2;  Werner, 
Die  Paranoia,  1891;  Schiile,  Allgem.  Zeitschr.  f.  Psy.,  L,  1  u.  2; 
Cramer,  ibid.,  LI,  2;  Sandberg,  ibid.,  LII,  619. 

423 


424  FORMS  OF   MENTAL  DISEASE 

There  is  as  yet  no  demonstrable,  pathological,  anatomical 
basis  peculiar  to  paranoia. 

Symptomatology.  —  The  development  of  the  psychosis 
is  very  gradual,  extending  sometimes  over  years,  and  is 
usually  so  insidious  that  the  disease  is  in  existence  long 
before  it  is  recognized.  During  this  period  it  may  have 
been  noticed  that  the  patient  had  changed  in  disposition, 
having,  become  somewhat  irritable,  grumbling,  suspicious, 
and  easily  discontented,  and  that  he  had  made  indefinite 
physical  complaints,  especially  of  malaise  and  insomnia. 

The  first  symptom  to  be  noticed  is  that  the  daily  mental 
or  manual  labor  becomes  distasteful,  and  little  affairs  at 
home  or  in  the  shop  cause  displeasure  and  arouse  suspicion. 
The  wife  seems  less  attentive,  the  children  less  loving, 
shopmates  less  friendly,  and  the  overseer  more  stern.  The 
accidental  absence  of  the  morning  greeting,  or  imaginary 
slight  on  the  part  of  a  close  friend,  sets  the  patient  to  think- 
ing that  it  cannot  all  be  accidental.  He  becomes  distrust- 
ful, is  constantly  seeking  other  evidences  of  unfriendliness, 
and  careful  watching  soon  satisfies  him  that  he  is  neglected, 
both  at  home  and  at  work.  He  begins  to  make  complaints, 
accuses  his  friends  of  slights,  and  members  of  his  fraternity 
of  plots.  He  leaves  his  employment,  holds  aloof  from  his 
companions  and  friends,  and  often  becomes  rude  and  dis- 
courteous. Some  patients  are  able  to  ignore  for  a  time  the 
apparent  indifference  of  friends,  but  others  become  much 
disturbed  and  suspect  a  malicious  purpose.  They  are  mor- 
bidly sensitive,  considering  that  such  trifles  as  harmless 
jokes,  smiles,  or  accidental  nods  of  the  head  have  special 
reference  to  themselves.  Items  in  the  paper  indicate  some 
intrigue,  bill  posters  contain  hints,  some  daily  passer  always 
lights  his  cigar  or  coughs  when  near  them;  men  similarly 
dressed  always  meet  them  near  the  same  corner,  or  are  shad- 


PARANOIA  425 

owing  their  footsteps.  Any  doubts  as  to  an  evident  pur- 
pose in  all  this  are  sooner  or  later  dispelled  by  remarks 
accidentally  overheard.  In  this  way  false  interpretations 
gradually  assume  greater  prominence,  and  the  resultant 
persecutory  delusions  are  constantly  increased  and  aggra- 
vated. Those  who  conscientiously  approach  and  question 
friends  or  supposed  intriguers  are  further  alarmed  and  justi- 
fied by  the  indifference  displayed  and  the  little  satisfaction 
obtained;  some  ignore  them,  others  answer  evasively. 
Trivial  matters  which  formerly  passed  unheeded  are  now 
falsely  and  absurdly  interpreted  and  enter  into  the  struc- 
ture of  their  delusions.  A  spot  on  the  coat,  a  calloused 
finger,  a  decayed  tooth,  or  a  headache  are  all  regarded  as 
positive  proof  of  treachery  and  an  effort  to  get  them  out 
of  the  way  by  a  slow  process  of  poisoning.  The  appearance 
of  natural  baldness  is  readily  explained  by  the  application 
of  electricity  during  sleep. 

Sooner  or  later,  in  connection  with  these  delusions  of 
persecution,  which  are  firmly  held  and  well  moulded  by  a 
coherent  train  of  reasoning,  there  may  also  appear  expan- 
sive delusions.  These  may  be  coincident  with  the  persecu- 
tory ideas  at  the  onset  of  the  disease,  but  more  frequently 
are  the  outcome  of  the  delusions  of  persecution.  The  in- 
creasing attention  which  the  patients  attract  and  the  per- 
sistent persecution  lead  them  to  cast  about  for  the  reason. 
While  some  find  this  in  property  which  they  really  possess, 
others  believe  that  it  lies  in  their  personal  charms,  while 
still  others  conclude  that  they  have  been  born  for  a  special 
mission,  or  are  of  noble  descent.  A  thrifty  Irish  woman,  who 
had  accumulated  considerable  property  by  dint  of  hardest 
labor,  finds  a  sufficient  cause  for  her  persecution  in  attempts 
of  her  enemies  to  secure  her  hard-earned  accumulations. 
A  factory  employee  already  approaching  the  limits  of  the 


426  FORMS  OF  MENTAL  DISEASE 

climacteric  finds  the  reasons  for  her  persecution  in  her 
attractive  appearance,  and  the  desire  of  eminent  men  to 
seduce  her.  Where  the  expansive  delusions  are  more  directly 
evolved  from  the  delusions  of  persecution,  the  patient  asks 
himself  why  he  is  so  molested  and  tormented,  why  so  many, 
not  only  individuals,  but  nations,  seem  directly  interested 
in  him,  and  why  he  is  constantly  accompanied  by  a  secret 
patrol.  Gradually  it  dawns  upon  him  that  he  is  a  kid- 
napped son  of  a  millionnaire  or  of  a  crowned  head,  that  he 
is  of  Napoleonic  descent  and  lawful  heir  to  the  throne, 
while  his  extensive  landed  properties  are  unlawfully  used 
by  the  government.  This  explanation  first  appears  in  the 
tendency  to  find  evidences  of  persecution  in  many  or  all 
the  events  of  their  environment,  and  becomes  prominent 
when  the  patients  discover  its  purpose.  Then  all  these 
supposed  facts  assume  a  place  in  the  chain  of  evidence 
which  confirms  their  conclusions. 

These  delusions  may  only  assume  the  form  of  an  exag- 
gerated feeling  of  self-importance.  The  patient  considers 
himself  especially  renowned  in  his  profession,  —  a  fine 
lawyer,  an  excellent  teacher,  an  interesting  talker,  an  ideal 
gentleman,  a  social  favorite,  or  an  individual  worthy  of 
great  political  distinction.  Finally,  a  change  of  personality 
may  result,  and  the  patient  announces  himself  as  titled,  or 
a  direct  descendant  of  Christ.  The  patients  become  aware 
of  this  in  various  ways,  one  once  receiving  a  salutation  from 
the  President,  another  recognizing  a  striking  similarity 
between  himself  and  the  equestrian  statue  of  a  famous 
general.  Others  are  assured  of  their  high  station  by  the 
deference  paid  them  by  every  one :  people  bow  to  them,  their 
names  are  in  the  paper,  the  orchestra  begins  to  play  as  they 
enter  the  theatre,  the  prima  donna  directs  her  song  at 
them,  and  the  birds  chirp  when  they  are  near.    The  appear- 


PARANOIA  427 

ance  of  the  sun  from  under  a  cloud,  casting  its  rays  upon 
them,  indicates  that  they  are  under  the  special  guidance  of 
God. 

All  delusions,  both  persecutory  and  expansive,  are  held  with 
great  persistency,  and  built  out  into  a  coherent  system,  which 
is  an  essential  characteristic  of  the  disease. 

In  the  systematization  of  the  delusions  another  promi- 
nent feature  is  the  frequent  appearance  of  retrospective 
falsification  of  memory.  While  this  symptom  is  mostly 
characteristic  of  paranoia,  it  may  also  be  present  in  the 
paranoid  forms  of  dementia  prsecox  and  in  melancholia. 
Here  the  patients,  in  reviewing  their  past  life,  find  evidences 
of  persecution,  or  detect  occurrences  which  at  the  time  should 
have  indicated  their  superiority.  The  loss  of  a  situation 
many  years  ago,  derisive  remarks  by  fellow-workmen,  or 
an  injury,  now  become  clear  evidences  of  their  persecution 
by  enemies.  One  patient  recalled  that  when  thirteen  years 
of  age  a  priest  took  from  her  a  book,  claiming  that  it  was 
unfit  for  her  to  read.  This  incident  she  now  regards  as  the  be- 
ginning of  years  of  persecution  by  the  priesthood,  who  would 
seduce  her  and  then  hold  her  up  as  an  example  before  the 
world.  Another  patient  led  his  class  in  marching,  and  later 
was  chosen  captain  of  the  boys'  brigade:  these  incidents 
at  that  time  should  have  made  him  aware  of  the  fact  that  he 
was  to  have  been  a  famous  general.  Another  remembered 
overhearing  his  parents  whisper  in  an  adjacent  room,  be- 
coming mute  at  his  entrance,  and  later  a  disguised  woman, 
who  was  really  his  mother,  visiting  at  the  house,  all  of  which 
pointed  to  a  noble  birth  and  his  displacement  by  a  younger 
brother.  Many  similar  incidents  scattered  throughout  life 
are  pointed  out  as  striking  evidences  which  aid  in  fortify- 
ing their  system  of  delusions. 

An  erotic  element  often  appears  in  the  delusions,  which 


428  FORMS  OF  MENTAL  DISEASE 

in  some  cases  has  been  pronounced  enough  to  lead  to  the 
recognition  of  an  erotic  paranoia.  Likewise,  the  religious 
coloring  is  sometimes  strong  enough  to  establish  a  religious 
paranoia. 

In  the  erotic  cases  the  patient  usually  believes  himself  the 
object  of  admiration  by  some  lady  who  is  attracted  to  him 
and  solicits  his  attention.  She  makes  him  aware  of  this 
by  daily  appearing  at  her  window  as  he  passes,  or  by  casting 
sly  glances  as  she  drives  by.  Other  evidence  is  gathered 
by  anonymous  love  poems  in  daily  papers.  Numerous 
fantastic  methods  of  communicating  his  love  to  her  are 
devised,  to  which  she  responds  by  wearing  certain  articles 
of  clothing,  or  arranging  her  hair  differently.  Their 
mutual  admiration  is  publicly  regarded  as  an  open  secret. 
He  hears  it  indirectly  referred  to  everywhere,  and  friends 
would  have  him  infer,  from  casual  remarks,  that  they  are 
well  pleased.  Sometimes  this  fanciful,  romantic,  and  even 
platonic  love  is  maintained  for  years  without  action;  at 
others  the  patient  makes  an  effort  to  approach  his  supposed 
fiancee.  Her  rebuffs  may  at  first  be  regarded  as  necessary 
for  the  accomplishment  of  her  desires.  Later  she  may 
appear  to  him  in  the  guise  of  one  of  his  companions. 

Hallucinations  are  always  present  at  some  time,  but  do 
not  play  a  very  important  part  in  the  psychosis,  and  rarely 
persist  through  the  whole  course  of  the  disease.  Hallucina- 
tions of  hearing  are  apt  to  be  the  most  prominent.  At  first 
very  indefinite  noises  annoy  them.  Later  they  hear  their 
names  mentioned,  or  derisive  laughter  from  a  crowd;  nick- 
names are  called  out,  some  one  curses  below  the  window, 
and  bits  of  conversation  from  adjoining  rooms  excite  them. 
The  remarks  are  more  often  of  a  depreciatory  nature.  Hal- 
lucinations of  sight  are  rare,  but  those  of  general  sensibil- 
ity are  quite  frequent,  —  the  hair  is  plucked  at  night,  the 


PARANOIA  429 

skin  irritated  by  poisonous  powder,  the  flesh  pierced  by 
bullets,  or  the  countenance  transformed  by  the  nightly 
application  of  an  iron  mask. 

There  is  never  genuine  insight  into  the  disease.  The 
patient,  on  the  other  hand,  may  complain  of  all  sorts  of 
physical  ailments,  such  as  nervousness,  indigestion,  pains 
in  the  head  and  back,  for  which  he  seeks  medical  attend- 
ance, but  he  cannot  be  made  to  realize  the  fallacy  of  his 
delusional  ideas.  The  memory  is  well  retained,  and  judg- 
ment, except  as  biassed  by  the  delusions,  is  unimpaired. 

The  emotional  attitude  of  the  patients  stands  in  direct 
relation  to  the  character  of  the  delusions.  They  are  irri- 
tated by  their  persecutors,  are  shy  and  excitable,  and  at 
first  usually  despondent;  some,  however,  tolerate  the  per- 
secution and  regard  it  as  essential  to  their  spiritual  wel- 
fare. All  sooner  or  later  become  arrogant,  proud,  and 
dogmatic. 

In  conduct  the  patients  appear  quite  normal  for  a  con- 
siderable time.  Some  of  them,  long  before  the  real  nature 
of  their  disease  becomes  evident,  attract  attention  by  their 
eccentricities,  peculiarities  in  dress,  oddities  in  manner, 
excessive  religious  zeal,  or  an  attitude  of  self-importance. 
Later  they  become  seclusive,  move  about  in  their  employ- 
ment from  city  to  city,  leave  one  shop  to  enter  another, 
where  they  soon  detect  the  presence  of  their  former  perse- 
cutors, and  are  again  compelled  to  leave.  In  this  way  an 
iron  moulder  travelled  from  San  Francisco  to  Boston  in 
order  to  avoid  the  persecutions  of  his  trade-union.  A  change 
affords  only  temporary  relief  to  the  anxiety,  as  suspicious 
circumstances  are  soon  noticed  which  leave  no  doubt  that 
news  about  them  has  been  passed  on  from  their  last  situa- 
tion until  finally  their  existence  becomes  known  the  world 
over.    They  become  unstable  in  their  behavior  and  mode  of 


430  FORMS  OF  MENTAL  DISEASE 

living,  are  unable  to  conduct  a  successful  business,  and  fail 
to  support  their  families.  In  reaction  to  the  delusions 
they  attempt  to  call  public  attention  to  their  persecution 
by  writing  newspaper  articles  and  issuing  pamphlets.  Very 
often  they  apply  to  the  police  for  protection.  Frequently 
they  assume  the  offensive,  and  take  the  matter  of  vengeance 
into  their  own  hands.  Not  infrequently  the  first  striking 
evidence  of  the  disease  is  a  murderous  assault  upon  some 
one.  The  paranoiac  is  for  this  reason  the  most  dangerous 
of  all  insane.  One  patient  assaulted  the  mayor  of  the  city 
for  keeping  him  from  his  fiancee;  another  drew  a  pistol  upon 
a  man  with  whom  he  was  having  an  altercation  over  business 
matters,  in  the  belief  that  he  was  the  secret  agent  of  the 
French  government  sent  to  kill  him. 

In  accordance  with  expansive  ideas  the  patient  may 
address  the  President  as  his  father,  or  demand  access  to  a 
millionnairess  whose  parents  are  keeping  them  apart.  If 
confined  in  an  institution,  they  may  for  a  time  ingeniously 
conceal  their  delusions  until  they  find  evidences  of  continued 
persecution  in  their  new  surroundings,  when  the  fellow- 
patients  appear  to  them  only  as  accomplices  placed  there 
to  aid  in  their  discomfort.  Sometimes  their  confinement 
is  regarded  as  an  effort  of  their  persecutors  to  make  them 
insane.  Some  patients  submit  gracefully  to  their  deten- 
tion, considering  it  but  another  cross  to  bear  before  their 
final  rescue  and  the  proclamation  that  they  are  rightful 
rulers.  A  few  patients  even  consider  that  they  are  being 
treated  with  the  utmost  consideration  and  the  greatest 
attention,  provided  with  the  best  quarters,  and  granted 
every  possible  privilege  by  those  who  recognize  the  great 
injustice  done  them. 

The  course  of  the  disease  is  protracted.  The  onset  is 
always  gradual,  and  usually  the  disease  has  been  in  prog- 


PARANOIA  431 

ress  for  some  time,  even  a  few  years,  before  recognition. 
When  once  established,  the  course  is  slowly  progressive, 
with  a  gradual  evolution  of  delusions  which  are  constantly 
being  further  systematized  and  made  to  encompass  new 
environment.  Several  psychiatrists  claim  that  the  course 
of  the  disease  presents  definite  periods  according  to  the 
stages  of  evolution  of  the  delusions.  At  first  there  is  the 
prolonged  period  of  insidious  onset,  by  Regis  called  the 
period  of  subjective  analysis,  followed  by  the  persecutory 
period  with  the  development  of  delusions  of  persecution 
with  hallucinations,  and  finally  the  ambitious  period  ac- 
companied by  a  change  of  personality.  The  patients 
usually  are  quite  orderly,  present  an  unclouded  conscious- 
ness, and  for  many  years  are  capable  of  considerable  labor, 
both  mental  and  manual.  After  a  duration  of  many  years 
there  appears  a  moderate  degree  of  mental  weakness.  Pa- 
tients become  unable  to  apply  themselves,  take  less  notice  of 
their  environment  and  less  care  of  themselves.  In  some 
cases  the  disease  may  seem  to  be  at  a  standstill  for  years, 
while  in  others  partial  remissions  occur  when  the  patients 
for  a  time  are  able  to  rejoin  their  families,  but  are  rarely  in 
a  condition  to  resume  their  accustomed  occupations. 

The  diagnosis  depends  upon  the  slow  onset,  the  charac- 
teristic, coherent,  and  systematized  delusions  of  persecution 
with  retrospective  falsifications  of  memory,  often  associated 
with  a  change  of  personality,  unclouded  consciousness, 
coherent  thought,  and  absence  of  mental  deterioration 
for  many  years. 

The  paranoid  forms  of  dementia  precox  have  already 
been  differentiated  from  paranoia  under  the  former  disease. 

A  few  cases  of  dementia  paralytica  and  melancholia  may 
simulate  paranoia.  Dementia  paralytica  is  to  be  distin- 
guished by  its  rapid  development,  the  early  appearance  of 


432  FORMS  OF  MENTAL  DISEASE 

emotional  weakness,  and  physical  signs.  The  conduct  of  a 
paranoiac  is  entirely  dependent  upon  the  content  of  the 
delusions;  he  cannot  be  reasoned  with,  is  persistent  in  the 
prosecution  of  his  ideas,  and  is  rarely  submissive  to  con- 
finement; while  the  paretic  opposes  his  retention  weakly 
or  intermittently  and  with  some  stubbornness. 

The  melancholiac  presents  a  more  rapid  onset  (three  to  nine 
months),  a  marked  disturbance  of  the  emotional  attitude, 
fear,  self-accusations,  occasional  clouding  of  consciousness, 
an  absence  of  system  in  the  formation  of  delusions,  and  evi- 
dences of  mental  deterioration  within  the  course  of  two  years. 

The  prognosis  of  the  disease  is  very  poor,  as  no  case  of 
genuine  paranoia  ever  recovers. 

The  treatment  of  the  disease  is  naturally  limited  to  the 
removal  of  irritating  influences  and  to  confinement  in  an 
institution  where  systematic  routine,  with  out-of-door  life 
and  ample  exercise,  may  ameliorate  or  ward  off  the  condi- 
tion of  mental  weakness. 

There  are  a  few  cases  of  paranoia  which  have  been  desig- 
nated by  Hitzig  as  querulent  insanity  (Querulantenwahn)1 
which  deserve  a  brief  description  here.  The  psychosis  is 
of  gradual  onset,  and  usually  arises  as  the  result  of  some 
legal  injustice,  —  a  defeat  in  court,  an  unjust  award  of 
damages,  loss  of  property,  or  an  unfair  adjustment  of  claims, 
in  which  the  patient  has  been  the  sufferer.  He  refuses  to 
settle,  carries  the  case  from  one  court  to  another,  and  finally 
develops  an  insatiable  desire  to  fight  to  the  bitter  end.  He 
reaches  a  point  where  he  is  unable  to  view  the  standpoint 
of  any  one  else  with  any  sense  of  justice,  and  his  personal 
belief  and  desire  completely  obscure  his  better  judgment. 
The  statutes  appear  inadequate,  and  even  the  fundamental 
principles  of  the  law  fail  of  comprehension.     He  sets  aside 

1  Hitzig,  Ueber  den  Querulantenwahn,  1895;  Koppen,  Archiv  f.  Pay., 
XXVIII,  221;  Pfister,  Allgem.  Zeitschr.  f.  Psy.,  LIX,  589. 


PARANOIA  433 

all  business  in  order  to  carry  on  the  struggle,  solicits  sym- 
pathizers, and  denounces  those  who  do  not  side  with  him. 
Hearsay  and  bits  of  knowledge  gathered  at  random  are  cited 
as  evidence  in  his  behalf,  and  money  is  squandered  in  the 
pursuit  of  justice  to  the  most  extreme  limits.  He  cannot 
abide  by  the  ultimate  decision  after  all  the  usual  means 
of  justice  have  been  exhausted.  Failing  to  appreciate  the 
needlessness  of  further  struggle,  he  writes  to  magistrates, 
legislators,  consuls,  ambassadors,  and  finally  to  the  Presi- 
dent or  foreign  rulers.  Answers  to  these  letters  only  create 
greater  embitterment.  His  letters  are  long  and  carefully 
written,  usually  upon  a  particular  kind  of  paper,  and  some- 
times written  with  colored  ink. 

The  patient  is  irritable  and  often  becomes  greatly  ex- 
cited in  conversation,  although  at  the  same  time  priding 
himself  upon  his  ability  to  exercise  self-control. 

Consciousness  remains  unclouded.  Memory  is  well  pre- 
served; in  fact,  it  is  often  surprising  to  see  with  what 
accuracy  he  is  able  to  quote  from  law  books,  to  repeat 
parts  of  speeches,  and  to  enumerate  various  dates.  Thought 
continues  coherent,  but  there  is  a  great  tendency  to  monoto- 
nous repetitions  of  the  delusions.  One  seldom  misses  them 
in  even  a  short  conversation. 

There  is  no  insight  into  the  condition.  On  the  other 
hand,  the  patient  is  often  encouraged  in  his  belief  by  the 
fact  that  there  are  always  many  men,  and  not  a  few  physi- 
cians, who  will  testify  to  his  sanity. 

The  few  cases  of  querulency  are  apt,  after  a  prolonged 
course,  to  present  greater  deterioration  than  other  varieties 
of  paranoia;  the  content  of  speech  becomes  more  and 
more  limited  and  somewhat  incoherent,  the  irritability 
increases,  the  patient  becoms  peevish,  indifferent,  and  some- 
times even  stupid. 

2f 


XI.   EPILEPTIC   INSANITY 

Epileptic  insanity  is  a  psychosis  based  upon  epilepsy 
which  is  characterized  by  a  variable  degree  of  mental  impair- 
ment and  by  the  recurrence  of  certain  transitory  mental  states, 
designated  epileptic  ill-humor  and  epileptic  befogged  states. 
The  befogged  states  include  pre-  and  post-epileptic  excitement 
and  stupor,  anxious  and  conscious  deliria,  and  possibly  also 
dipsomania. 

Etiology.  —  Defective  heredity  is  the  most  frequent  pre- 
disposing cause  of  epilepsy,  appearing  in  eighty-seven  per 
cent,  of  cases,  while  in  over  twenty-five  per  cent,  epilepsy 
exists  in  the  parents.  Spratling !  found  in  1070  cases 
hereditary  taint  in  fifty-six  per  cent.,  sixteen  per  cent. 
of  which  displayed  parental  epilepsy.  He  also  found 
nearly  similar  ratios  in  parental  alcoholism  and  tuber- 
culosis. Fere2  notes  among  progenitors  and  relatives  of 
epileptics  the  extreme  frequency  of  migraine,  headaches, 
infantile  convulsions,  mental  disturbances,  and  deteriora- 
tion. All  authorities  agree  that  parental  alcoholism  is  a 
prolific  source  of  epilepsy  in  the  offspring.  Wildermuth 
considers  its  influence  almost  as  powerful  as  that  of  mental 
disorders,  including  epilepsy.  Other  factors  in  the  pro- 
genitors which  predispose  to  epilepsy  are  insanity,  syphilis, 
rheumatism,  diabetes,  and  possibly  chorea.  Evidences  of 
congenital  defect  are  frequently  found  in  malformation  or 
asymmetry  of  skull,  microcephaly,  hydrocephalus,  the  so- 
called  "  epileptic  physiognomy  "  (broad  forehead,  broad  and 

1  Spratling,  Epilepsy  and  its  Treatment,  1904. 

2  Fere,  Les  Epilepsies,  1890. 

4?A 


EPILEPTIC  INSANITY  435 

flattened  nose,  prognathism,  thick  lips,  and  staring  eyes 
with  wide  pupils),  feeble-mindedness,  precocity,  moral  delin- 
quency, and  sexual  perversion. 

Among  the  exciting  or  immediate  causes  of  epilepsy  we 
find  cerebral  palsies,  dentition,  emotional  shocks  (fright, 
excitement,  anxiety,  grief),  many  acute  infections,  meningi- 
tis, thermic  fever,  overwork,  gastro-intestinal  disorders,  dis- 
ease of  heart  and  kidneys,  tobacco,  lead,  and  other  poisons, 
carious  teeth,  foreign  bodies  in  the  ear,  and  even  sexual 
intercourse. 

Head  injuries,  such  as  blows,  falls,  brain  lesions  (especially 
hemorrhages),  are  frequently  assigned  as  the  cause  of  epi- 
lepsy, and  in  a  certain  number  of  cases  a  direct  relation 
between  them  can  be  traced.  Wildermuth  gives  their 
frequency  as  three  and  eight-tenths  per  cent.,  and  Heeres 
as  four  and  two-tenths  per  cent.  Spratling  says  that 
"  trauma  is  more  frequently  the  cause  of  epilepsy  in  men 
than  in  women  (eight  and  five- tenths  per  cent,  men  :  three 
and  five-tenths  per  cent,  women)."  The  numerous  scars 
often  found  on  the  head  are  more  frequently  the  results 
than  the  causes  of  the  malady. 

Alcoholic  excesses  are  by  far  the  most  important  causes  of 
epilepsy  beginning  after  the  tv/entieth  year.  About  ten 
per  cent,  of  chronic  alcoholics  are  thus  afflicted.  All  epi- 
leptics present  a  marked  intolerance  to  alcohol,  and  its 
use  by  them,  even  in  small  quantities,  hastens  the  onset  and 
intensifies  the  symptoms  of  mental  disorder.  Many  imbe- 
ciles and  idiots  and  a  few  seniles  (thirty-four  hundredths 
per  cent.)  develop  epilepsy. 

Epilepsy  is  essentially  a  disease  of  youth,  convulsions 
appearing  in  thirty-four  per  cent,  of  cases  in  infancy. 
Spratling  found  in  ten  hundred  and  seventy  cases  twenty- 
six  and  five-tenths  per  cent,  develop  under  the  age  of  five 


436        '  FORMS  OF  MENTAL  DISEASE 

years ;  nineteen  per  cent,  from  five  to  nine  years ;  twenty- 
four  and  four-tenths  per  cent,  from  ten  to  fourteen  years; 
and  thirteen  and  six- tenths  per  cent,  from  fifteen  to  nine- 
teen years,  —  a  total  of  fifty-six  and  five-tenths  per  cent, 
under  twenty  years.  Gowers  found  in  fourteen  hundred 
and  fifty  cases  that  in  seventy-four  and  eight-tenths  per 
cent,  the  onset  occurred  before  the  twentieth  year. 

Pathology.  —  As  not  all  epileptics  are  insane,  it  is  evident 
that  the  pathology  of  epileptic  insanity  must  be  based  upon 
that  of  the  seizures  plus  hereditary  taint,  constitutional 
defect,  and  other  factors  whose  nature  and  influence  are 
not  yet  thoroughly  known.  There  is  a  wide  variation  in 
views  as  to  the  nature  of  epilepsy,  but  it  is  now  generally 
regarded  as  a  cortical  disease  which  is  general  and  profound. 
Gross  lesions  are  of  secondary  importance  and  mostly  act 
as  contributing  factors.  Among  the  most  important  gross 
changes  revealed  by  autopsy  are  alterations  in  the  texture 
and  shape  of  the  skull,  old  lesions  of  infantile  cerebral 
hemiplegia  (four  to  ten  per  cent.),  sclerosis  of  the  cornu 
ammonis,  porencephaly,  encephalic  scars,  neoplasms,  etc. 
Wildermuth  asserts  that  thirteen  and  three-tenths  per  cent, 
of  his  cases  were  due  to  polioencephalitis,  and  five  and 
eight-tenths  per  cent,  to  other  gross  lesions.  In  the  re- 
maining eighty- three  and  nine-tenths  per  cent,  of  his  cases  — 
called  "  genuine  "  or  idiopathic  epilepsy  —  various  ana- 
tomical changes  were  found  in  the  brain,  which  probably 
bore  some  relation  to  the  clinical  symptoms.  The  micro- 
scopic changes  thus  far  found  are  cortical  gliosis  and  nu- 
merous cortical  cell  changes,  such  as  chromatolysis;  while  in 
late  epilepsy  we  find  arteriosclerosis  and  occasionally  syphi- 
litic lesions.  It  is  possible  and  very  probable  that  many 
of  the  lesions  found  in  the  brain  are  the  results  of  epilepsy 
and  not  the  causes. 


EPILEPTIC  INSANITY  437 

The  periodicity  of  the  seizures  may  possibly  be  explained 
by  the  apparent  tendency  in  the  nervous  system  to  a  periodi- 
cal reaction  to  any  continued  irritation.  If  the  researches  of 
Krainsky,  Cabitto,  Agostini,  and  others  can  be  corroborated, 
it  would  seem  probable  that  idiopathic  epilepsy  is  due  to  a 
toxic  condition  arising  from  faulty  metabolism,  and  that  the 
immediate  cause  of  the  convulsions  is  the  accumulation  of 
deleterious  substances  in  the  blood  or  a  faulty  chemotaxis 
of  the  cortical  cells.  This  theory  receives  further  weight 
from  the  fact  that  the  convulsions  are  frequently  accom- 
panied by  symptoms  which  point  to  intoxication,  as  drowsi- 
ness, headache,  nausea,  etc.;  and  also  from  the  fact  that 
epileptiform  attacks  occur  in  many  conditions  of  chronic 
intoxication,  especially  from  alcohol,  lead,  and  uremia. 
"  From  the  nature  of  the  cortical  cell  changes  we  have  a 
right  to  expect  that  the  inciting  agents  will  be  very  active 
nuclear  poisons." l 

It  is  now  believed  that  the  blood,  sweat,  urine,  and 
gastric  contents  are  hypertoxic  for  some  time  before,  during, 
and  after  the  seizures,  and  hypotoxic  in  the  intervallary 
periods,  but  no  definite  conclusion  as  to  the  sources  of  this 
alteration  in  toxicity  has  been  reached.  Epilepsy  due  to 
circumscribed  lesions,  traumatic  or  otherwise,  of  the  brain, 
can  hardly  be  ascribed  to  toxicity  alone.  Even  if  we  should 
base  the  known  cerebral  changes  upon  a  chronic  intoxica- 
tion, we  would  still  need  to  explain  the  periodicity  of  the 
attacks,  the  accumulation  of  toxins,  and  also  the  heredi- 
tary relationship  of  epilepsy  to  other  mental  and  nervous 
diseases.  On  the  whole,  it  seems  probable  that  the  ultimate 
and  characteristic  cause  of  the  symptom-complex  epilepsy  is 
to  be  found  in  morbid  conditions  of  the  nervous  tissues,  espe- 
cially the  cortical  cells,  most  likely  due  to  chemical  changes. 

1  Spratling,  Epilepsy  and  its  Treatment. 


I 


438  FORMS  OF  MENTAL  DISEASE 

Symptomatology.  —  Epilepsy  unquestionably  produces 
some  mental  deterioration  in  every  case,  but  in  about  fifty 
per  cent,  this  is  slight,  chiefly  affecting  the  memory.  The 
most  striking  feature  of  the  epileptic  weakmindedness  is 
the  slow  evolution  of  psychic  processes,  external  stimuli 
arousing  only  a  meagre  response  in  consciousness.  In  the 
majority  of  cases  of  epileptic  insanity  the  degree  of  deteriora- 
tion once  established  may  remain  without  marked  progress 
for  years  or  even  life.  In  a  few  cases,  however,  a  condition 
of  profound  deterioration  may  be  reached. 

Hallucinations  are  exceedingly  infrequent  except  in  the 
befogged  states  and  anxious  and  conscious  deliria.  When 
present  in  the  interparoxysmal  periods,  they  generally  have 
a  religious  character.  Illusions  are  quite  frequent  for  a 
short  period  before  and  after  attacks  of  grand  mal.  Con- 
sciousness is  usually  clear  and  orientation  normal  in  the 
intervallary  periods,  except  during  the  befogged  states. 
Apprehension  of  the  daily  routine  is  fairly  keen,  but  atten- 
tion is  always  somewhat  impaired  or  easily  fatigued. 

Memory  is  always  impaired,  sometimes  to  a  great  extent. 
While  prominent  events  and  the  ordinary  daily  routine  may 
be  recalled,  the  recollection  of  the  general  course  of  life, 
whether  remote  or  recent,  is  more  or  less  hazy.  In  contrast 
to  the  memory  defects  found  in  other  deterioration  psy- 
choses, patients  are  able  to  express  clearly  and  coherently 
their  remaining  narrow  circles  of  thought. 

The  train  of  thought  shows  a  marked  atrophy  of  the  store 
of  ideas  with  scanty  assimilation  of  new  impressions.  In 
conversation  and  writing  there  is  a  strong  tendency  to  detail 
and  circumstantiality.  Their  narratives  are  obscured  by 
a  multitude  of  data  and  irrelevant  or  unessential  accessories 
which  greatly  impede  the  progress  toward  and  development 
of  the  goal  ideas.    The  connection  is  not  lost,  however,  and 


EPILEPTIC  INSANITY  439 

the  goal  is  ultimately  reached.  The  religious  content  of 
thought  is  another  striking  symptom,  many  patients  spend- 
ing a  large  part  of  their  time  in  reading  the  Bible  or  in 
praying  aloud.  Patients  adhere  to  familiar  paths,  and  their 
vocabulary  consists  largely  of  set  phrases,  platitudes,  Bible 
texts,  proverbs,  etc.  The  narrowness  of  thought  naturally 
leads  to  a  greater  prominence  of  the  ego.  This  is  especially 
noticeable  in  the  conversation  of  epileptics,  in  which  they 
indulge  in  praise  of  self  and  family,  and  pay  much  attention 
to  personal  matters. 

The  imagination  is  practically  inactive,  if  not  entirely 
abolished,  and  epileptics  show  no  ability  to  reconstruct  or 
recombine  the  materials  furnished  by  old  experiences  or  new 
perceptions.  They  occasionally,  however,  write  verse  which 
shows  an  unruly  and  riotous  fancy,  as  in  the  following: — 
"E  is  the  eel  who  soars  to  the  sky; 
F  is  the  finch  who  is  fond  of  pie." 

Judgment  invariably  becomes  impaired  as  mental  deteriora- 
tion progresses,  but  delusions  are  not  common  except  in  some 
of  the  transitory  epileptic  mental  states,  when  they  are 
accompanied  by  hallucinations.  Many  epileptics  become 
hypochondriacal.  The  true  relation  of  ideas  is  obscured  or 
even  lost,  and  "  common  sense,"  tact,  and  discretion  are 
seldom  displayed.  Patients  never  adequately  recognize  the 
incongruity  between  their  plans  and  their  limited  ability. 
One  man  with  marked  mental  and  physical  defects,  whose 
schooling  had  been  meagre,  gravely  proposed  to  study  the- 
ology; and  another  who  could  hardly  name  the  simplest 
flowers  desired  to  become  a  florist.  As  a  rule,  however, 
epileptics  have  some  insight  into  their  condition,  realizing 
that  they  have  convulsions,  poor  memory,  and  difficulty  of 
thought. 

Among  the  most  marked  symptoms  are  those  occurring  in 


440  FORMS  OF  MENTAL  DISEASE 

the  emotional  field,  even  when  mental  deterioration  is  not 
advanced.  There  is  almost  always  an  increased  irritability 
manifested  by  their  peevishness,  obstinacy,  unruliness,  also 
by  frequent  outbreaks  of  emotional  excitement  as  well  as 
sudden  alternations  from  elation  to  depression,  and  the 
reverse.  This  is  particularly  apt  to  occur  in  the  proximity 
of  the  convulsions  and  is  easily  aroused  by  alcohol.  Some 
patients  complain  of  an  "  internal  anguish,"  or  fear.  They 
are  easily  angered,  are  threatening,  quarrelsome,  violent,  and 
dangerous.  Usually  the  finer  feelings  become  blunted,  and 
there  often  exists  a  uniform  state  of  apathy.  On  the  other 
hand  there  are  a  few  patients  who  for  years  always  display 
a  placid,  amiable  disposition,  free  from  evidences  of  irrita- 
bility. 

Morbid  and  sudden  impulses  are  frequent  and  characteris- 
tic symptoms  of  epileptic  insanity.  These  are  largely  due 
to  increased  irritability  or  lack  of  self-control.  Patients  will 
attack  any  one  who  disturbs  them,  and  often  in  a  blind  rage 
suddenly  inflict  severe  and  dangerous  injuries,  even  on  inno- 
cent and  inoffensive  bystanders,  without  any  provocation. 
These  impulses  are  by  no  means  confined  to  the  pre-  or 
post-paroxysmal  stages,  as  many  suppose,  but  may  arise  at 
long  intervals  between  the  seizures.  The  wild  state  of  blind 
rage,  where  patients  run  amuck,  striking  and  assaulting 
indiscriminately  every  one  in  their  range,  —  the  characteristic 
epileptic  furor,  —  is  a  nerve  storm  which  may  justly  be  con- 
sidered as  an  "  equivalent."  These  sudden  impulses  to  vio- 
lence and  even  homicide  render  epileptics  especially  dan- 
gerous. Suicidal  impulses  are  very  infrequent,  and  their 
accomplishment  still  more  so. 

The  conduct,  apart  from  the  stubbornness  and  morbid  im- 
pulses above  described,  is  usually  good.  Epileptics  as  a 
rule  are  neat,  orderly,  and  observe  the  usual  convention- 


EPILEPTIC  INSANITY  441 

alities  unless  deterioration  is  quite  marked.  Some  patients 
display  marked  sexual  excitement,  and  some  are  inveterate 
masturbators.  All  epileptics  show  a  diminished  capacity 
for  work,  especially  where  the  higher  grades  of  mental  and 
physical  training  are  requisite.  They  may  engage  with  fair 
success  in  simple  routine  occupations  where  little  or  no 
initiative  is  required,  but  unless  carefully  directed  and  super- 
vised, are  apt  to  slight  their  work  or  leave  it  unfinished. 

Physical  Symptoms.  —  The  most  important  physical  symp- 
toms in  epileptic  insanity  are  the  convulsions,  which  may 
assume  the  type  of  grand  or  petit  mal.  In  the  former  there 
may  be  an  aura,  followed  by  a  cry,  a  fall,  and  tonic  followed 
by  clonic  convulsions,  usually  localized  at  first,  but  rapidly 
extending  over  the  entire  body.  During  the  convulsions, 
which  may  last  from  two  to  ten  minutes,  consciousness  is 
totally  abolished,  but  returns  gradually  within  a  period  of  a 
few  minutes  up  to  several  hours.  In  status  epilepticus  there 
may  be  from  twenty  to  even  several  hundred  attacks  of 
grand  mal,  without  a  return  to  consciousness  in  the  inter- 
vals. In  petit  mal  there  is  a  very  brief  loss  of  consciousness 
(usually  only  one  or  two  seconds),  either  without  any  con- 
vulsive movements  or  with  very  slight  ones  which  often 
elude  observation. 

The  reflexes  are  abolished  during  the  convulsions,  and  in 
some  cases  are  not  restored  for  one  or  more  hours.  In  1088 
observations  on  male  epileptics,  Keniston1  found  that  the 
normal  plantar  reflex  (flexion  of  toes,  etc.)  was  present  in 
both  feet  immediately  after  clonus  had  ceased  in  forty-five, 
and  one  hour  later  in  two  hundred  twenty-six,  cases;  the 
Babinski  phenomenon  (extension  of  toes  with  dorsiflexion 
of  ankle)  occurred  in  one  hundred  three  cases  directly  after 
the  seizure,  and  in  one  hundred  twelve  cases  one  hour  later. 
1  Keniston,  Journ.  of  Amer.  Med.  Assoc,  March  21,  1903. 


442  FORMS  OF  MENTAL  DISEASE 

An  extensor  response  was  found  in  right  or  left  foot  in  ninety- 
nine  and  fifty-three  cases,  respectively,  and  a  flexor  response 
in  right  or  left  foot  in  ninety-nine  and  two  hundred  eleven 
cases,  respectively,  while  a  mixed  response,  that  is,  extension 
in  foot  and  flexion  in  the  other,  occurred  in  eighty-two  cases 
directly  after  a  seizure  and  in  one  hundred  forty-seven  cases 
one  hour  later.  The  plantar  reflex  was  abolished  in  six  hun- 
dred sixty  cases  immediately  after  the  convulsions,  and  in 
three  hundred  thirty-nine  cases  one  hour  later.  The  knee- 
jerks  were  active  in  three  hundred  ninety-six  cases, 
moderate  in  one  hundred  thirty-seven,  and  absent  in  five 
hundred  thirty-nine  cases. 

The  speech  of  epileptics  is  often  altered  and  very  char- 
acteristic. It  is  abrupt,  with  intervals  after  each  phrase, 
often  drawling,  jerky,  or  strongly  accented.  During  ex- 
citement it  may  be  so  rapid  as  to  be  indistinguishable,  were 
it  not  for  the  fact  that  a  few  phrases  are  repeated  over  and 
over  again.  Tuberculosis  and  organic  and  functional  dis- 
eases of  the  heart  are  quite  frequent,  and  the  pulse  rate  is 
often  increased.  Epileptics  rarely  complain  of  headache, 
and  often  show  an  insensibility  to  pain  amounting  to  anal- 
gesia, while  their  frequent  wounds  usually  heal  rapidly. 
Richter  found  anaesthetic  areas  in  forty  per  cent,  of  his 
cases,  general  analgesia  in  twelve  and  two-tenths  per  cent., 
and  hemihypsesthesia  in  ten  and  two-tenths  per  cent. 
Paresthesias  are  very  common.  Sleep  is  often  irregular 
and  muscular  strength  diminished.  Appetite  is  usually 
good,  and  most  epileptics  are  greedy  and  gluttonous.  As 
residuals  of  seizures  we  find  scars  of  all  kinds,  especially 
on  the  head,  broken  noses,  extensive  burns,  and  absence 
of  front  teeth;  and  as  causal  residuals  we  see  evidences  of 
alcoholic  abuses,  sequellae  of  early  brain  diseases,  syphilitic 
or  arteriosclerotic  alterations,  and  cranial  scars.     We  occa- 


EPILEPTIC  INSANITY  443 

sionally  find  after  seizures  small  cutaneous  hemorrhages, 
particularly  in  the  conjunctiva. 

In  addition  to  the  above  general  mental  and  physical 
symptoms  which  constitute  the  epileptic  dementia,  there 
occur  with  more  or  less  regularity  certain  transitory  epileptic 
mental  states,  which  occur  periodically  and  independently  of 
external  causes. 

The  most  important  of  these  states  is  the  periodical  ill- 
humor,  which  according  to  Aschaffenburg  occurs  in  78  per 
cent,  of  epileptics  and  is  characterized  by  a  marked  emotional 
tension  without  much  involvement  of  consciousness. 

The  separate  attacks  bear  an  extraordinary  resemblance 
to  each  other.    The  same  complaints,  the  same  delusions? 
and  the  same   impulses  recur.    The  phraseology  of  the 
patients  is  definite,  the  behavior  characteristic,  and  the  ex- 
pression similar.    These  attacks  vary  in  intensity,  and  often 
come  on  in  the  morning.     Sometimes  the  intervals  are  so 
regular  that  the  time  of  recurrence  can  be  foretold  with 
tolerable  accuracy.    Patients  usually  awake  peevish,  irri- 
table, fault-finding,  threatening,   and   quarrelsome;    often 
commit  sudden  and  unprovoked  assaults  on  the  nearest  per- 
son; break  glass  or  destroy  bedding  and  furniture,  and  use 
profane  or  obscene  language.     Very  often  the  emotional 
condition  is  one  of  anxiety,  when  the  patients  complain  of 
feeling  homesick,  and  low  spirited,  and  of  being  troubled 
with  sad  thoughts,  have  presentiments,  and  express  delusions 
of  self-accusation.     Occasionally  hallucinations  also  appear. 
At  the  same  time  the  patients  may  complain  of  feelings  of 
numbness,  pressure  in  the  head,  ringing  in  the  ears,  and 
difficulty  of  thought.    They  are  unable  to  work,  wander 
about,  sometimes  remain  in  bed,  and  frequently  attempt 
suicide.    Less  often  the  patients  develop  a  state  of  expan- 
siveness  or  ecstasy.    They  then  run  about  with  glaring  eyes 


444  FORMS  OF  MENTAL  DISEASE 

and  happy  countenances.  They  shout,  throw  things  about, 
and  get  into  all  kinds  of  trouble,  tease  their  mates,  pray 
loudly,  and  express  expansive  religious  ideas.  Occasionally 
there  is  a  flight  of  ideas.  Furthermore  there  is  great  emotional 
irritability  with  a  tendency  to  aggressiveness.  Some  patients 
rapidly  develop  a  condition  of  marked  excitement.  Some- 
times the  patients  develop  a  delusional  state  with  emotional 
irritability  and  anxiety  and  also  occasionally  accompanied 
by  hallucinations,  which  condition  might  be  termed  a 
paranoid  condition. 

While  the  ill-humor  usually  occurs  after  a  seizure,  it  may 
precede  it,  in  which  case  the  convulsion  generally  clears  the 
mental  atmosphere.  The  attacks  rarely  last  more  than  a 
few  hours,  but  may  persist  for  a  week  or  more.  Abatement 
is  gradual,  and  is  often  followed  by  a  feeling  of  complacency 
or  well-being.  In  some  cases  the  hallucinations  and  delu- 
sions may  persist  with  little  change  for  weeks  or  months, 
simulating  closely  certain  conditions  found  in  dementia 
praecox,  but  finally  the  hallucinations  and  delusions  en- 
tirely disappear. 

Befogged  states  represent  the  second  large  group  of  transi- 
tory epileptic  states,  and  are  characterized  by  a  more  or  less 
profound  clouding  of  consciousness.  These  states  include 
pre-  and  post-epileptic  insanity,  psychic  epilepsy,  epileptic 
stupor,  anxious  delirium,  conscious  delirium,  some  cases  of 
somnambulism,  and  possibly  dipsomania.  The  befogged  states 
are  sometimes  preceded  by  the  transitory  states  of  ill-humor 
just  described.  Alcohol  may  predispose  to  them,  even  when 
taken  in  very  moderate  quantities. 

Pre-epileptic  Insanity. —  Here  all  sorts  of  morbid  sensory 
impressions  may  arise,  —  flashes  of  light,  impairment  of 
vision,  indefinite  or  strange  sounds,  peculiar  odors,  and 
paresthesias,  —  which  are  not  to  be  confounded  with  the 


EPILEPTIC  INSANITY  445 

individual  aura,  when  such  exists.  There  may  be  fixed 
ideas,  falsified  identifications,  monotonous  repetitions  of 
words  or  phrases,  involuntary  or  grotesque  movements, 
and  imperative  impulses,  as  to  strike,  destroy  furniture,  or 
kill.  In  a  short  time  —  sometimes  a  few  minutes  or  even 
seconds  —  consciousness  becomes  clouded,  and  the  con- 
vulsion begins.  In  a  few  cases  the  latter  passes  over  into 
a  pronounced  dreaminess  lasting  for  hours  or  days. 

Post-epileptic  Insanity.  —  It  is  more  common  and  is  char- 
acterized by  deep  dazedness  after  the  seizure,  lasting  for 
hours  or  even  days.  Patients  do  not  understand  questions, 
speak  confusedly  (paraphasia),  are  completely  disoriented, 
wander  aimlessly  about,  collect  all  obtainable  objects,  and 
even  drink  their  urine.  While  active  sensory  disturbances 
are  undoubtedly  present,  no  account  can  be  obtained  from 
the  patients,  who  have  complete  amnesia  of  all  that  has 
happened.  As  a  rule,  they  recover  their  normal  mental 
and  emotional  attitude  very  gradually. 

Psychic  Epilepsy. — Mental  and  emotional  disturbances 
very  similar  to  the  above  may  appear  in  the  intervallary 
periods,  entirely  independent  of  the  convulsions,  and  are 
then  called  "  equivalents/'  or  psychic  epilepsy.  These  con- 
ditions are  by  no  means  rare,  and  are  frequently  observed 
in  hospitals.  They  are  more  liable  to  occur  in  patients  who 
have  seizures  at  long  intervals.  The  essential  feature  of 
psychic  epilepsy  is  the  disturbance  of  consciousness.  Patients 
are  confused,  move  and  act  in  a  mechanical  or  automatic 
manner,  and  often  present  evidences  of  illusions,  hallucina- 
tions, and  delusions.  They  wander  aimlessly  about,  and  do 
not  appear  to  recognize  any  one,  but  will  sometimes  reply 
incoherently  to  questions.  Occasionally  they  assume  fixed 
or  peculiar  positions,  or  gaze  steadily  at  one  point.  In  some 
instances  they  display  a  heightened  excitement,  and  again 


446  FORMS  OF  MENTAL  DISEASE 

a  gloomy  stupor,  during  which  they  may  masturbate,  ex- 
pose their  person,  or  attempt  sexual  assaults.  Patients 
have  been  known  to  set  fire  to  their  bedding  or  furniture  for 
such  trivial  purposes  as  boiling  coffee,  etc.  The  numerous 
criminal  acts,  such  as  theft,  arson,  assaults,  and  even  homi- 
cide, committed  during  these  periods  demonstrate  the  ex- 
treme importance  of  the  recognition  of  psychic  equivalents 
in  their  medicolegal  aspect.  The  history  of  previous  attacks 
of  grand  or  petit  mal,  even  if  very  infrequent,  the  senseless- 
ness of  the  actions,  with  utter  absence  of  motive  or  attempt 
at  concealment,  and  either  complete  amnesia  or  only  a  very 
hazy  recollection  of  what  has  happened,  should  make  the 
diagnosis  clear.  These  attacks  usually  last  only  a  short 
time,  —  seconds  or  minutes,  —  but  occasionally  continue  for 
an  hour  or  more. 

Under  the  head  of  psychic  epilepsy  should  be  included  some 
cases  of  somnambulism,  occurring  in  epileptics.  Patients  no- 
tice only  those  objects  which  are  directly  in  front  of  them. 
The  eyes  may  be  closed,  half-opened,  or  staring.  Movements 
usually  display  evidences  of  automatism,  but  there  may  be 
traces  of  deliberation  and  purpose,  as  in  avoiding  obstacles. 
Sometimes  higher  psychic  fields  are  involved,  and  patients 
may  carry  on  long  conversations,  compose  poems,  or  transact 
business.  Next  morning  they  do  not  remember  what  they 
have  done,  but  may  complain  of  lassitude,  stiffness,  or  sore- 
ness. 

Epileptic  Stupor. — Here  the  clouding  of  consciousness  is 
intense  and  prolonged.  Patients  may  eat,  speak,  or  per- 
form certain  mechanical  movements,  but  always  as  if  dream- 
ing and  without  clear  understanding.  Sometimes  the  eyes 
are  closed,  or  the  face  dazed  or  staring.  The  same  attitude 
is  maintained  for  hours  or  even  days,  and  the  expression 
justifies  the  inference  that  confused  terrorizing  delusions 


EPILEPTIC  INSANITY  447 

dominate  the  emotional  sphere,  although  occasionally  the 
demeanor  indicates  happiness  or  religious  ecstasy.  Patients 
show  absolute  indifference  to  their  environment,  never 
answer  questions,  remain  in  bed,  and  soil  themselves.  They 
sometimes  show  active  resistance  if  disturbed,  may  make 
sudden  impulsive  attacks,  and  instinctive  suicidal  attempts 
are  not  infrequent.  The  reflexes  are  abolished,  sensibility 
is  blunted,  and  in  single  cases  temporary  catalepsy  is  seen. 
Nourishment  is  often  refused,  either  wholly  or  partially. 
Epileptic  stupor  usually  lasts  from  one  to  two  weeks,  but 
in  severe  cases  the  course  is  longer.  Recollection  of  the 
events  is  mostly  lost.  Improvement  is  generally  gradual, 
but  in  a  few  cases  the  confusion  may  disappear  in  one  day. 
Where  attacks  are  repeated  and  prolonged,  patients  may 
remain  for  a  long  time  dull  and  inattentive. 

Anxious  Delirium.  —  This  form  is  more  frequent  than 
stupor  and  may  occur  independently  of  seizures.  The  mental 
disturbance  is  profound.  The  attack  develops  suddenly, 
and  may  be  preceded  by  very  brief  periods  of  ill-humor, 
characteristic  sensations,  and  numbness,  or  by  fixed  and 
regularly  recurring  hallucinations,  as  red  objects,  flames,  etc. 
Apprehension  is  dulled,  surroundings  are  changed,  and 
orientation  is  lost.  The  hallucinations  and  delusions  are 
usually  terrifying :  patients  must  be  punished,  must  die,  are 
surrounded  by  devils,  animals,  or  throngs  of  people  who 
come  out  of  the  walls  or  floor.  They  wade  in  blood,  their 
parents  are  perishing,  the  house  is  blown  into  the  air,  or 
everything  is  sinking.  Sometimes  God  or  Christ  appears  and 
carries  them  in  splendid  chariots  to  heaven,  but  these  trans- 
ports are  only  transitory,  and  the  predominant  tone  of  their 
emotions  is  one  of  fear  and  dread.  Patients  are  impelled  to 
brutal  and  incredible  outrages,  as  cutting  up  their  parents 
or  children,  shooting,  stabbing,  etc.   They  run  away  to  escape 


448  FORMS  OF  MENTAL  DISEASE 

the  horrors  which  confront  them.  With  flushed  faces,  either 
silent  or  howling  and  shrieking,  they  rage  furiously,  with 
prodigious  strength,  destroying  everything  within  reach. 
The  duration  of  anxious  delirium  varies  from  a  few  hours 
to  two  weeks.  Sometimes  consciousness  clears  up  suddenly 
after  a  long  sleep,  but  usually  gradually,  so  that  transitory 
hallucinations,  delusions,  and  normal  ideas  are  mixed  to- 
gether in  a  characteristic  manner.  There  is  no  recollection 
of  events  occurring  during  the  height  of  the  delirium. 

Conscious  Delirium.  —  This  is  a  rare  form,  which  either 
follows  a  seizure  or  appears  as  a  psychic  equivalent.  Patients 
appear  from  their  conduct  to  be  conscious,  but  in  reality 
consciousness  is  greatly  clouded,  while  numerous  illusions 
and  hallucinations  may  inspire  false  ideas  of  danger.  Ex- 
pansive ideas  are  not  uncommon.  Answers  to  simple  ques- 
tions are  coherent  and  relevant,  but  the  whole  demeanor,  if 
closely  observed,  discloses  some  confusion  and  disorientation. 
The  disposition  is  irritable,  usually  anxious,  but  sometimes 
elated,  and  delusional  ideas  often  lead  to  impulsive  acts. 
Legrand  du  Saulle  reports  the  case  of  a  merchant  who,  on 
suddenly  recovering  from  an  attack,  found  himself  on  the 
way  to  Bombay.  Others  have  committed,  with  seemingly 
unclouded  consciousness,  senseless  and  even  criminal  acts 
(thefts,  arson,  rebellion,  desertion,  indecent  assaults)  with- 
out any  insight  into  their  significance.  Attacks  of  con- 
scious delirium  may  last  for  days,  weeks,  or  even  months, 
and  there  may  be  a  series  of  attacks  separated  by  short 
intervals. 

Dipsomania  in  many  respects  resembles  epilepsy,  as  it 
presents  an  apparently  paroxysmal  and  periodical  impulse 
to  senseless  alcoholic  excesses.  Among  the  prodromal  symp- 
toms are  noted  uneasiness,  anxiety,  fear,  despondency, 
weariness  of  life,  increased  irritability,  a  feeling  of  heaviness 


EPILEPTIC  INSANITY  449 

in  the  head,  anorexia,  insomnia,  and  occasionally  sexual 
excitement.  Very  rapidly  after  these  manifestations  there 
appears  an  impulsive  and  irresistible  desire  to  obtain  relief, 
which  is  found  in  a  "  mad  rush  "  for  liquor.  Some  patients 
develop  a  typical  epileptic  befogged  state,  in  which  they  be- 
come abusive,  aggressive,  noisy,  and  undertake  foolish  jour- 
neys. One  man  had  attacks  once  in  two  years,  when  in  the 
space  of  two  days  he  would  drink  several  pints  of  whiskey, 
ultimately  becoming  completely  unconscious,  and  often,  on 
coming  to  his  senses,  finding  himself  in  strange  places. 
After  several  of  these  attacks,  he  arranged  that  friends  should 
take  him  to  a  hospital  on  the  first  appearance  of  the  pro- 
dromes. 

Some  dipsomaniacs  present  no  typical  epileptic  disturb- 
ances, but  in  their  attacks  fall  suddenly  into  a  condition 
resembling  inebriety,  in  which  they  continue  without  in- 
terruption —  day  and  night  —  to  drink  large  quantities  of 
beer,  wine,  gin,  or  spirits,  until  they  have  spent  their  last 
cent,  and  even  sold  their  clothing  to  obtain  means  for 
gratification  of  their  morbid  appetite.  During  these  attacks 
intoxication  is  seldom  complete,  but  consciousness  is  clouded, 
and  patients  retain  only  a  hazy  recollection  of  a  few  events 
of  their  debauch,  but  often  manifest  deep  contrition  and  an 
abhorrence  of  alcohol.  Convalescence  is  gradual,  and  some- 
times accompanied  by  nausea,  anorexia,  gastric  catarrh,  un- 
steadiness, and  tremors,  while  a  few  cases  present  symptoms 
of  collapse,  accompanied  by  delirium  and  hallucinations. 

The  attacks  of  dipsomania  may  recur  without  any  external 
cause,  and  in  the  intervals,  which  may  last  for  weeks,  months, 
or  even  years  in  a  few  instances,  patients  have  no  craving 
for  alcohol,  and  either  totally  abstain  or  drink  very  moder- 
ately. There  are  many  transitions  or  variations  from  the 
characteristic  picture  of  dipsomania.     Some  patients  mani- 

2c 


450  FORMS  OF  MENTAL  DISEASE 

fest  a  disposition  similar  to  that  of  epileptics,  and  a  few 
perhaps  present  during  life  only  one  instance  of  an  epileptic 
befogged  state  accompanying  an  attack  of  inebriety. 

Diagnosis.  —  The  diagnosis  of  epileptic  insanity  is  gener- 
ally easy  as  soon  as  we  can  establish  the  existence  of  the 
characteristic  convulsions.  It  should,  however,  be  differen- 
tiated from  hysteria,  dementia  paralytica,  and  the  cata- 
tonic form  of  dementia  prsecox. 

In  hysterical  insanity  consciousness  is  less  deeply  dis- 
turbed in  the  seizures,  and  we  almost  never  see  sudden  in- 
voluntary falls,  serious  injuries,  or  biting  of  the  tongue. 
The  seizures  are  also  specially  induced  by  external  influences, 
as  mental  emotions,  physicians'  visits,  etc.,  and  may  be  cur- 
tailed or  suddenly  aborted  by  very  lively  excitement  or 
strenuous  treatment.  The  development  is  more  diversified 
than  that  of  the  epileptic  seizure,  which  is  always  uniform. 
In  hysteria  tonic  and  clonic  muscular  contractions  of  the 
entire  body,  convulsions  of  the  diaphragm,  opisthotonus, 
jactitation,  rolling  on  the  ground,  somersaults,  lively  move- 
ments of  expression  (dramatic  and  passionate  attitudes), 
alternate  even  in  the  same  attack,  and  consciousness  is  never 
abolished.  Dilatation  and  immobility  of  the  pupils,  usually 
considered  an  important  characteristic  of  epilepsy,  have 
recently  been  found  in  hysteria  also.  We  find  in  hysteria 
extravagant  caprices,  rapid  changes  of  disposition,  and 
dependence  on  external  influences,  while  in  epilepsy  there 
is  a  rough  irascibility,  a  limited  waywardness,  an  inde- 
pendent periodicity,  and  a  prominent  ill-humor.  Mental 
weakness  is  more  frequent  and  pronounced  in  epilepsy. 

In  epilepsy  coming  on  in  middle  life,  we  must  consider  the 
possibility  of  dementia  paralytica,  which  sometimes  begins 
with  epileptiform  seizures.  Here  the  consideration  of  the 
other   symptoms,   such  as   impaired   pupillary  reflex   and 


EPILEPTIC  INSANITY  451 

inequality,  characteristic  speech  disturbances,  ataxia,  incoor- 
dination, etc.,  will  soon  clear  up  the  diagnosis.  When,  how- 
ever, the  epileptiform  attacks  occur  at  long  intervals,  and 
are  accompanied  by  one  or  more  of  the  above  symptoms,  we 
should  be  prepared  for  the  possibly  gradually  developing 
symptoms  of  dementia  paralytica. 

The  epileptic  befogged  state  has  been  mistaken  for  the 
initial  stage  of  the  catatonic  form  of  dementia  prcecox.  In 
the  latter  we  find  negativism,  passive  resistance,  senseless 
answers,  rapid  and  correct  execution  of  commands,  eccen- 
tricities, and  stereotypy,  with  absurd  acts,  and  less  dis- 
turbance of  apprehension  and  orientation.  In  epilepsy 
there  is  anxious  resistance  with  indifference  to  orders,  and 
uniformity  of  conduct,  while  there  are  frequent  assaults, 
atrocities,  and  attempts  to  escape.  Special  weight  attaches 
to  the  previous  history  and  the  proof  of  separate  attacks  of 
vertigo  or  syncope,  periodical  ill-humor,  and  probable  night 
attacks,  as  evidenced  by  occasional  enuresis,  injuries  to  the 
tongue,  and  severe  lassitude  or  headache  in  the  morning. 

The  diagnosis  of  the  befogged  states,  when  only  one  con- 
vulsion has  been  observed  during  life,  or  perhaps  not  even 
one,  but  only  a  brief  syncope,  presents  some  difficulties;  but 
we  must  remember  that  while  the  convulsion  is  a  very  im- 
portant symptom  of  epileptic  insanity,  it  may  be  absent  or 
replaced  by  an  "  equivalent."  Hence  the  periodicity  of 
the  attacks,  clouding  of  consciousness,  morbid  impulses, 
crimes  committed  without  motive  or  attempt  at  conceal- 
ment, amnesia,  and  rapid  course  will  facilitate  the  diagnosis. 

Prognosis.  —  This  depends  essentially  on  the  cause  of  the 
epilepsy  and  the  time  of  onset.  When  dependent  on  gross 
brain  lesions,  recovery  is  out  of  the  question,  and  the  mental 
weakness  often  progresses  to  complete  deterioration.  When 
following  head  injuries,  some  recoveries  have  occurred,  and 


452  FORMS  OF  MENTAL  DISEASE 

in  many  cases  decided  and  long-continued  improvement  has 
resulted. 

Genuine  epilepsy  may  disappear  spontaneously,  but  recur- 
rence is  common  if  life  is  prolonged,  and  in  the  interval  there 
is  usually  some  mental  dulness  with  transient  ill-humor. 
Improvement  rarely  occurs  in  cases  where  the  befogged 
states,  especially  stupor,  have  occurred,  if  they  have  been 
at  all  frequent.  In  some  cases  of  anxious  delirium  death 
occurs  from  exhaustion.  Conscious  delirium  is  not  danger- 
ous to  life,  but,  like  anxious  delirium,  if  recurring  at  short 
intervals,  tends  to  hasten  the  progress  of  deterioration. 

In  epilepsy  arising  late  in  life  the  outlook  is  very  un- 
favorable. On  the  other  hand,  in  alcoholic  epilepsy  treat- 
ment is  often  successful  in  effecting  a  cure,  or  at  least  great 
improvement.  On  the  whole,  while  in  some  cases  patients 
may  improve  sufficiently  to  go  home,  especially  where  the 
disturbance  is  largely  in  the  emotional  sphere,  the  prognosis 
of  epileptic  insanity  is  unfavorable,  and  patients  should  be 
subjected  to  prolonged  observation  and  treatment  before 
one  assumes  the  risk  of  discharging  them.  This  is  all  the 
more  desirable  as  attacks  of  furor  may  occur  without  any 
seizures,  and  thus  the  patient  becomes  a  danger  to  the  com- 
munity. As  far  as  life  is  concerned,  we  must  remember 
that  serious  and  even  fatal  injuries  may  result  from  acci- 
dents occurring  during  the  convulsions  or  from  the  develop- 
ment of  status  epilepticus.  Worcester  found  that  sixty  per 
cent,  of  epileptics  die  as  the  result  of  their  seizures. 

Treatment.  —  As  far  as  the  medical  treatment  of  epileptic 
insanity  is  concerned,  little  can  be  done  except  to  attend  to 
bodily  needs  and  combat  any  unfavorable  symptoms  which 
may  arise.  On  the  other  hand,  moral  treatment,  by  which 
is  meant  suitable  occupation  and  diversion,  out-door  life, 
helpful  suggestions,  educational  efforts  to  retard  the  progress 


EPILEPTIC  INSANITY  453 

of  deterioration  and  conserve  what  mental  equipment  is 
left,  is  of  the  highest  value  and  an  absolute  necessity. 
Every  one  who  possesses  a  remnant  of  physical  or  mental 
power  should  be  obliged  to  do  something.  Occupation  should 
be  light,  safe,  avoiding  high  or  dangerous  places,  varied,  and 
with  ample  intervals  of  rest.  Diversions  should  be  simple 
and  wholesome,  and  all  reading  should  be  carefully  selected, 
consisting  largely  of  history,  biography,  light  essays,  stand- 
ard novels,  and  religious  subjects  which  would  help  toward 
right  living  and  avoid  all  exciting  or  controversial  points 
which  might  intensify  the  religiosity  to  which  almost  all 
epileptics  are  prone. 

The  treatment  of  epilepsy  itself  should  be  based  on  well- 
known  principles.  Nutrition  should  be  fostered  by  careful 
attention  to  the  alimentary  system.  The  diet  should  be 
regulated,  and  may  consist  of  fruits;  cereals  in  moderation 
and  thoroughly  cooked ;  eggs,  breads,  milk,  cocoa,  chocolate, 
and  a  minimum  of  tea  and  coffee;  simple  puddings,  such  as 
rice,  farina,  and  custard;  fish  and  a  moderate  amount  of 
meat,  at  noon  only.  The  supper  should  be  very  light  and 
taken  at  least  two  hours  before  retiring.  All  meals  should 
be  regular,  and  patients  should  be  carefully  supervised  to 
insure  thorough  mastication  and  prevent  "  bolting  "  food. 
The  reduction  of  salt  in  food  has  been  advocated,  not  only  to 
diminish  the  irritability  arising  therefrom,  but  to  enable  us 
to  materially  decrease  the  amounts  of  bromids  prescribed. 
It  is  said  that  this  method  diminishes  by  one-half  the  chance 
of  bromism.  Toulouse  and  Richet  have  introduced  the 
hypochlorization  method,  which  consists  in  using  sodium 
bromid  in  place  of  ordinary  salt,  ten  grains  of  the  former 
being  equal  to  twenty  grains  of  the  latter. 

The  kidneys  require  attention,  and  the  secretion  of  urine 
should  be  stimulated  by  a  free  use  of  water.    The  skin 


454  FORMS  OF  MENTAL  DISEASE 

should  be  kept  in  good  condition,  and  occasional  hot  baths 
employed  to  induce  perspiration.  If  eye  strain  or  other 
ocular  symptoms  are  present,  they  should  be  remedied. 
The  teeth  and  mouth  must  be  kept  in  a  healthy  state. 

It  is  very  important  to  insist  on  complete  and  permanent 
abstinence  from  alcohol  in  all  cases,  and  not  merely  in  alco- 
holic epilepsy  and  dipsomania.  Every  epileptic  is  more  or 
less  intolerant  of  its  effects,  very  severe  mental  and  emo- 
tional disturbances  often  result  from  its  use,  and  nothing 
is  to  be  gained  from  it  in  any  case. 

While  innumerable  remedies  have  been  used  to  control  or 
abort  the  seizures,  their  utility  is  somewhat  doubtful,  since 
the  convulsions  are  practically  safety  valves,  which  allow  the 
elimination  of  toxins.  Unless  the  cause  can  be  removed,  it 
is  perhaps  better  to  allow  the  insane  epileptic  to  have  his 
fits,  as  they  often  clear  the  mental  atmosphere.  Neverthe- 
less, in  the  present  state  of  medical  and  lay  opinion,  it  is 
advisable  in  every  case,  at  the  beginning,  to  administer  the 
bromids,  either  singly  or  in  various  combinations,  with 
proper  precautions,  until  after  due  trial  we  can  decide  from 
the  general  condition  of  each  patient  —  mentally,  emo- 
tionally, and  physically  —  whether  or  no  it  is  best  to  con- 
tinue their  use.  They  should  be  given  at  the  start  in  very 
small  doses  (6  to  8  grains)  three  times  daily,  after  meals,  in 
plenty  of  water,  gradually  increasing  the  amount  until  the 
point  of  saturation  is  reached,  which  is  indicated  by  the  dis- 
appearance of  the  throat  reflex.  Then  the  dose,  which  varies 
with  the  individual,  should  be  reduced  more  or  less  gradually 
until  we  establish  a  norm  which  can  be  continued  for  a  long 
time,  even  years,  with  occasional  short  interruptions.  In 
some  cases  the  epileptic  disturbances  disappear,  not  even 
returning  when  the  medicine  is  suspended,  and  we  may 
perhaps  regard  the  case  as  cured.     It  must  be  borne  in 


EPILEPTIC   INSANITY  455 

mind,  however,  that  in  a  certain  number  of  cases  the  seizures 
cease  spontaneously  without  any  treatment,  not  to  recur 
for  years,  if  ever.  Hence  we  must  not  attach  too  much  im- 
portance to  the  curative  power  of  the  bromids. 

Should  bromism  occur,  as  evidenced  by  acne,  digestive 
disturbances,  bronchial  disorders,  cardiac  weakness,  increase 
of  the  reflexes,  anaesthesias,  impairment  of  memory,  stupor, 
etc.,  the  bromids  should  at  once  be  discontinued  and  an 
eliminative  and  supporting  treatment  instituted,  —  free  and 
regular  evacuations  of  bowels  and  bladder,  promotion  of 
normal  skin  action,  and  the  use  of  digitalis  and  strychnin 
in  small  and  decreasing  doses,  supplemented  by  absolute 
rest  in  bed  and  a  simple,  easily  digested  diet. 

Among  the  other  countless  remedies  employed  to  control 
the  seizures  may  be  mentioned  argenti  nitras,  brom-ethyl, 
atropia,  oxid  of  zinc,  borax,  adonis  vernalis,  and  the  Flechsig 
treatment  by  a  regular  course  of  opium  in  increasing  doses, 
followed  by  bromids,  with  rectal  lavage,  and  strict  confine- 
ment to  bed.  While  all  these  have  given  satisfactory  results 
in  some  cases,  none  are  so  generally  useful  as  the  bromids. 

When  status  epilepticus,  which  is  comparatively  infrequent 
among  the  insane,  occurs,  compression  of  the  carotids  should 
be  tried  if  the  arterial  tension  is  very  strong.  Full  doses  of 
bromid,  opium,  and  chloral  in  combination  may  be  given  at 
intervals  of  two  hours,  by  mouth  or  rectum,  and  inhalation 
of  ether  or  chloroform  be  tried.  Combat  exhaustion  and 
collapse,  and  treat  all  complications  promptly,  especially 
supporting  the  heart. 

Treatment  directed  to  the  causes  of  epilepsy  is  not  promis- 
ing in  insanity,  as  the  disease  has  been  of  too  long  duration. 
Hence  head  operations  are  usually  contra-indicated.  The 
time  to  operate  for  trauma,  etc.,  is  when  the  lesion  occurs, 
or  immediately  thereafter.    The  prevention  of  epilepsy  can 


456  FORMS  OF  MENTAL  DISEASE 

only  be  secured  by  preventing  marriages  of  the  epileptic, 
insane,  defective,  and  alcoholics. 

Finally,  in  view  of  the  liability  to  assaults  and  injuries  to 
self  or  others,  every  epileptic  should  be  under  constant  sur- 
veillance at  all  times,  night  and  day. 


XII.   THE  PSYCHOGENIC  NEUROSES 

Neuroses  are  commonly  designated  as  a  group  of  diseases 
characterized  by  changing  and  transitory  nervous  disturb- 
ances, to  be  distinguished  from  psychoses  by  the  fact  that 
the  symptoms  do  not  involve  the  mental  field.  But  in  prac- 
tice psychoses  without  nervous  symptoms  or  neuroses  with- 
out mental  symptoms  are  not  encountered.  Among  the 
neuroses  there  is  a  distinctive  group  of  cases,  the  individual 
symptoms  of  which  are  of  a  purely  psychogenic  origin.  This 
group,  which  comprises  hysterical  insanity,  traumatic  neu- 
rosis, and  dread  neurosis,  is  in  general  characterized  by 
a  more  or  less  marked  hysterical  constitution,  the  numerous 
manifestations  of  which  are  seen  on  every  side.  While 
traumatic  neurosis  and  dread  neurosis  are  closely 
related  to  hysterical  insanity,  they  are,  however,  charac- 
terized by  a  different  method  of  development,  by  different 
clinical  symptoms,  and  a  different  course. 

A.     Hystekical  Insanity1 

Although  it  is  difficult  to  give  a  perfectly  satisfactory 
definition  of  hysterical  insanity,  it  may  be  described  as  a 

1  Moebius,  Schmidt's  Jahrbucher,  199,  2,  185  (Literatur) ;  Xeurologische 
Beitrage,  I ;  Monatsschr.  f .  Geburtshilfe  und  Gynkaologie,  I,  12 ;  Pitres, 
Lecons  cliniques  sur  l'hysterie  et  l'hypnotisme,  1891 ;  Gilles  de  la  Tour- 
ette,  Traite  clinique  et  therapeutique  de  l'hysterie,  1891 ;  Janet,  Der 
Geisteszustand  der  Hysterischen  (die  psychischen  Stigmata) ,  deutsch  von 
Kahane,  1894;  Sollier,  Genese  et  nature  de  l'hysterie,  1897;  L'Hysterie 
et  son  traitement,  1901 ;  Ziehen,  Eulenburgs  Realencyclopaedie,  3.  Auf- 
lage;   Krehl,  Ueber  die   Entstehung  hysterischer  Erscheinungen ;  Volk- 

457 


458  FORMS  OF  MENTAL  DISEASE 

neurosis  in  which  mental  states  produce  manifold  physical 
symptoms  with  extraordinary  ease  and  facility. 

Etiology.  —  Hysteria  develops  upon  a  morbid  constitu- 
tional basis.  Defective  heredity  occurs  in  seventy  to  eighty 
per  cent,  of  cases.  An  equally  important  factor  is  the  influ- 
ence of  defective  education  and  training.  Other  factors  are 
trauma,  shock,  acute  and  chronic  diseases.  Mental  stigmata 
are  often  recognized  in  early  life;  as,  irritability,  waywardness, 
indolence,  talkativeness,  undue  piety,  and  sudden  and  rapid 
changes  of  emotional  attitude.  Sometimes  such  physical 
disturbances  as  chorea,  headache,  and  loss  of  speech  have 
been  noted.  More  than  two-thirds  of  the  patients  are 
women. 

In  children,1  in  whom  the  disease  is  more  prevalent  among 
males,  special  symptoms  are  more  prominent,  as  mutism, 
reflex  convulsions,  paralyses,  and  attacks  of  screaming, 
convulsive  coughing,  and  silly  befogged  states  (Chorea 
Magna).  These  symptoms  are  easily  produced  by  physical 
injuries,  but  more  especially  by  emotional  disturbances,  and 
not  infrequently  result  from  psychical  infection  (school 
epidemics).  Poverty,  seclusion,  and  faulty  physique  favor 
their  development. 

Hysteria  does  not  often  develop  in  adult  life,  although  the 
symptoms  may  become  more  prominent  during  the  climac- 
terium. The  role  played  by  the  disturbance  of  the  female 
sexual  organs  in  the  production  of  the  disease  is  not  clear. 
On  the  one  hand,  it  has  been  observed  that  disturbances  of 
these  organs  may  produce  severe  physical  and  mental  dis- 
orders   without    creating    hysterical    symptoms,    that    the 

manns  klinische  Vortrage,  Neue  Folge,  330,  1902;  Fuerstner,  Deutsche 
Klinik,  VI,  2,  155,  1901 ;  Jolly  in  Ebstein  u.  Schwalbe,  Handbuch  der 
praktischen  Medizin. 

1  Bruns,  Die  Hysterie  im  Kindesalter,  1897 ;  Sanger,  Monatsschr.  f . 
Psy.,  LX,  321. 


THE  PSYCHOGENIC  NEUROSES  459 

disease  sometimes  appears  long  before  puberty,  and  finally 
that  it  develops  in  individuals  with  normal  sexual  organs. 
On  the  other  hand,  it  is  known  that  uterine  disturbances 
frequently  exist  and  are  a  source  of  complaint,  and  that  the 
relief  of  even  minor  uterine  disorders  leads  to  a  marked  im- 
provement. It  seems  probable,  therefore,  that  disorders  of 
the  female  sexual  organs  act  only  as  prominent  exciting 
causes. 

Pathology.  —  The  true  nature  of  the  disease  is  still  un- 
known. A  short  and  satisfactory  explanation  is  that  hysteria 
is  a  congenital  morbid  mental  state  whose  chief  characteristic 
lies  in  the  fact  that,  as  Moebius  expresses  it,  physical  symp- 
toms are  produced  "  by  ideas."  To  this  might  be  added  that 
these  ideas  are  strongly  emotional,  and,  indeed,  also  indefi- 
nite. This  would  account  for  the  fact  that  the  physical 
symptoms  do  not  always  correspond  to  the  character  of  the 
stimulus  or  to  the  content  of  the  ideas,  that  they  can  appear 
in  fields  not  accessible  to  the  influences  of  the  will,  and  some- 
times are  not  even  noticed  by  the  patients.  The  internal 
relation  between  sadness  and  tears  is  no  better  understood 
than  that  between  fright  and  hemianesthesia.  Terror  can 
cause  a  movement  of  the  bowels  and  whitened  hair,  just  as 
hysteria  can  produce  edema  and  disturbances  of  the  heart's 
action.  Even  clouding  of  consciousness  may  be  brought 
about  by  states  of  feeling.  While  it  must  be  confessed  that 
this  is  not  an  entirely  satisfactory  explanation  of  the  nature 
of  hysteria,  yet  it  seems  probable  that  increased  emotional 
excitement  and  the  morbid  prominence  and  duration  of  the 
involuntary  expressions  that  accompany  it  play  an  impor- 
tant role  in  the  production  of  the  disease. 

There  is  no  known  anatomical  pathological  basis  for  the 
disease. 

Symptomatology.  —  Apprehension    presents    no    striking 


460  FORMS  OF  MENTAL  DISEASE 

disturbance.  On  the  contrary,  many  patients  exhibit  an 
uncommon  sensitiveness;  they  are  very  keen  in  the  per- 
ception of  details  in  the  environment,  and  especially  any 
defects.  A  few  patients  are  gifted  along  certain  lines,  while 
others  are  dwarfed  mentally.  Although  the  patients  appear 
vivacious  and  bright,  close  observation  discloses  distracti- 
bility  and  lack  of  sound  judgment.  They  are  easily  attracted 
by  anything  new  or  striking,  are  deeply  impressed  by  show, 
become  the  clients  and  champions  of  the  most  recent  phy- 
sician, and  adopt  peculiarities  in  dress  and  ornament.  This 
weakness  is  observed  especially  in  the  field  of  religion.  They 
are  eager  for  sensation,  and  take  pleasure  in  gossip  and  in 
all  sensuous  enjoyments. 

Memory  is  generally  accurate,  yet  it  is  often  not  well 
balanced.  Furthermore,  what  is  perceived  is  not  always 
correctly  interpreted.  In  some  cases  there  is  a  marked 
tendency  not  only  to  amplify  events  of  the  past,  but  even  to 
distort  them  by  pure  fabrications.  Patients  will  rehearse 
startling  personal  experiences  and,  in  order  to  make  their 
tales  all  the  more  credible,  will  present  marks  of  violence, 
which  they  themselves  have  made.  In  such  cases  there  is 
no  doubt  that  the  patients  consciously  deceive  in  order  to 
arouse  sympathy  or  to  cause  a  sensation.  But  in  the  minor 
variations  from  the  truth  shown  by  the  average  hys- 
terical patient  it  is  difficult  to  say  how  much  is  intentional 
deception  and  how  much  is  due  to  the  subjugation  of 
memory  by  a  lively  imagination.  In  some  cases,  no  doubt, 
the  imagination  dominates  entirely  all  thought  and  action 
without  creating  the  picture  of  a  real  delusion. 

Disturbances  in  the  emotional  attitude  are  very  important 
symptoms.  The  fluctuation  of  the  feelings  determines  to  a 
large  extent  the  whole  mental  life  of  the  patient.  Their 
influence  is  stronger  than  rational  deliberation  or  moral 


THE  PSYCHOGENIC  NEUROSES  461 

principles.  Patients  are  excitable,  and  take  an  active  per- 
sonal interest  in  everything  around  them,  are  extraordinarily 
sensitive,  and  exhibit  a  tendency  to  outbursts  of  feeling  on 
slight  provocation.  Occasionally  there  is  heightened  sexual 
excitement,  but,  on  the  other  hand,  there  may  be  an  absence 
of  all  sexual  feeling.  Frequent  and  abrupt  changes  in  the 
emotional  attitude  are  also  characteristic.  One  never 
knows  where  to  find  the  patients ;  they  pass  abruptly  from 
a  state  of  merriment  into  passionate  anger ;  at  one  moment 
they  may  be  distastefully  sentimental,  at  the  next  crotchety 
and  antagonistic. 

This  increase  in  the  emotional  irritability  is  perhaps  a 
cause  of  the  concentration  of  thought  upon  self.  Some  pa- 
tients even  seem  to  take  pleasure  in  meditating  upon  and 
busying  themselves  over  their  ill-health.  Thus  numerous 
hypochondriacal  ideas  originate  and  dominate  thought. 
Moreover,  emotional  depression  has  a  more  powerful  influ- 
ence than  in  the  normal  person  in  producing  all  sorts  of 
physical  ailments.  The  ease  with  which  this  influence  is 
excited  and  the  variety  of  the  symptoms  are  especially  char- 
acteristic of  the  hysterical  constitution.  Insignificant  feel- 
ings of  discomfort  receive  undue  attention,  and  may  even 
create  sensations  of  injury.  Real  complaints  are  greatly 
exaggerated  by  the  lively  imagination  of  the  patient  until 
hypochondriacal  ideas  are  evolved.  Genuine  pain  arising 
from  a  definite  lesion  fails  to  disappear  with  the  removal  of 
the  cause,  but  continues  indefinitely,  and  may  even  become 
more  widespread.  The  headache  and  backache  coincident 
with  menstruation  may  be  the  foci  from  which  there  arises  a 
grievous  and  agonizing  condition,  the  symptoms  of  which  the 
patients  rehearse  in  all  detail  on  every  possible  occasion. 

Patients  develop  a  most  remarkable  attitude  toward  their 
disease.    They  believe  that  it  is  an  object  of  distinction,  and 


462  FORMS  OF  MENTAL  DISEASE 

even  become  proud  of  their  invalidism.  This  is  also  evi- 
dent in  their  failure  to  cooperate  in  treatment.  Although 
complaining  bitterly,  they  lack  all  feeling  of  personal  re- 
sponsibility in  carrying  out  treatment,  and  may  even  stub- 
bornly refuse  to  assist.  However,  any  new  or  striking 
method  of  treatment,  although  it  may  entail  some  suffering, 
often  will  be  undertaken  for  the  sake  of  notoriety.  Many 
refuse  to  deny  themselves  the  pleasures  of  life,  and  con- 
tinue to  attend  entertainments,  to  visit  and  receive  com- 
pany, in  spite  of  the  claim  that  their  suffering  is  even 
enhanced  by  such  endeavors. 

Many  patients  complain  particularly  of  mental  suffering : 
terrible  thoughts  that  constantly  torture  them,  ungrounded 
fears,  the  memory  of  the  failures  of  their  lives,  etc.  These 
are  repeated  over  and  over  at  every  opportunity  with  great 
show  of  emotion,  but  not  without  emphasizing  their  own 
heroic  struggle  or  martyrlike  submission.  Occasionally  they 
wish  they  were  dead  and  utter  threats  of  suicide ;  sometimes 
they  make  melodramatic  and  even  absurd  attempts,  such 
as  tying  a  ribbon  about  the  neck  or  jumping  into  shallow 
water. 

The  numerous  hypochondriacal  complaints  necessitate 
constant  medical  attendance.  Some  patients  develop  a 
state  of  absolute  dependence  upon  one  physician.  On  the 
other  hand,  it  is  not  unusual  for  patients  to  change  phy- 
sicians frequently,  to  visit  celebrities  and  ask  for  many  con- 
sultations. They  often  fall  into  the  hands  of  quacks  who 
gratify  them  by  offering  some  wonderful  cure.  These  cures, 
if  effected,  are  usually  as  transitory  as  they  are  striking. 

An  exaggerated  self-consciousness  is  a  common  symptom. 
Hysterical  patients  are  markedly  self-conscious,  and  display 
a  corresponding  lack  of  regard  for  the  interests  of  others. 
They  perceive  with  morbid  acuteness  any  encroachment 


THE  PSYCHOGENIC  NEUROSES  463 

upon  their  own  comfort,  but  accept  the  most  extreme  sacri- 
fice on  the  part  of  others  as  a  mere  matter  of  course.  They 
are  always  exacting  beyond  reason,  dissatisfied  with  the 
best  efforts  of  others,  and  deeply  grieved  over  neglect  or  lack 
of  sympathy.  The  insatiable  cravings  of  many  hysterical 
patients  develop  out  of  this  heightened  self-consciousness. 
Dissatisfied  with  what  they  have,  they  are  constantly  asking 
for  something  new,  usually  objects  difficult  to  obtain,  —  new 
furniture,  new  quarters,  new  clothing,  different  food,  etc. 
It  is  often  surprising  to  see  how  undeserving  patients  success- 
fully establish  intimate  relations  with  churches,  societies, 
and  well-meaning  philanthropists,  who  gratify  the  most 
unreasonable  demands.  These  patients  regularly  tyrannize 
the  family. 

In  the  volitional  field  the  most  pronounced  symptom  is 
an  increased  susceptibility  to  external  influences.  Patients 
yield  readily  to  all  sorts  of  influences,  quickly  become  en- 
thusiastic in  any  cause  and  just  as  quickly  lose  interest.  In 
contrast  to  this  extraordinary  pliancy  of  the  will  to  the  most 
varied  and  insignificant  conditions  there  is  frequently  ob- 
served the  apparent  opposite  state  of  wilfulness.  When 
patients  "  get  something  into  their  head,"  they  are  most 
obstinate  and  headstrong  in  their  purpose.  Some  subject 
themselves  to  great  discomfort  and  pain,  even  torture  them- 
selves, and  refuse  to  eat  or  speak  without  any  apparent 
reason.  In  reality  these  apparently  contradictory  states  of 
the  will  arise  out  of  the  pliancy  of  the  will  to  accidental  influ- 
ences, whether  they  are  external  impressions  or  personal 
fancies.  The  unreasonable  and  impulsive  conduct  of  the 
hysterical  patient  arises  from  the  same  source. 

Consequently,  in  conduct  the  patients  are  unstable  and 
erratic,  and  change  rapidly  from  one  act  to  another  without 
sufficient  reason.    Because  they  lack  uniformity  and  per- 


464  FORMS  OF  MENTAL  DISEASE 

sistency,  there  develops  more  or  less  restlessness,  which  stands 
out  in  strong  contrast  to  their  physical  weakness  and  help- 
lessness. They  have  a  pressure  to  do  something,  to  take 
part  in  something,  to  distinguish  themselves,  to  do  some  mis- 
chief, and  they  long  for  adventure.  In  manner  they  are  at 
times  vivacious  and  frank,  at  others  reserved  and  bashful, 
or,  again,  silly  and  sentimental.  They  are  demonstrative 
and  often  express  themselves  in  the  most  exaggerated  terms. 
Their  vehemence  of  expression  by  no  means  always  corre- 
sponds to  the  intensity  of  their  feelings,  as  the  latter  often 
fluctuate  rapidly  from  one  state  to  another.  Patients 
characterize  their  own  condition  by  such  expressions  as 
"  Most  horrible  !"  "Excruciating  !"  "  Inexpressible  !"  and  in 
depicting  their  suffering  it  is  not  unusual  for  them  to  add 
color  to  the  description  by  copious  weeping  or  even  fainting. 
In  spite  of  their  intense  misery,  the  thought  of  self-enjoy- 
ment usually  remains  in  evidence.  One  patient,  after  filling 
several  sheets  of  her  home  letter  with  the  most  horrible  self- 
execrations,  closed  with  the  request  for  macaroons. 

The  capacity  for  employment  is  impaired;  the  patients 
have  no  disposition  for  earnest  and  strenuous  occupation, 
lack  perseverance,  are  weak  and  easily  exhausted,  and  always 
feel  that  they  must  spare  themselves.  On  the  other  hand, 
they  pass  much  time  with  trifles,  arranging  and  rearranging 
pretty  ornaments  in  the  rooms,  and  dillydallying  with  their 
toilet  and  personal  adornment. 

Physical  Symptoms.  —  The  physical  symptoms  of  hysteri- 
cal insanity  are  wholly  functional  and  are  often  referred  to 
as  "  stigmata."  They  consist  chiefly  of  different  degrees  of 
paralyses  of  a  single  limb,  astasia  abasia,  choreiform  move- 
ments, contractures,  localized  and  general  convulsions, 
aphonia,  impairment  of  speech,  numerous  sensory  disturb- 
ances,   including    paresthesia,   anaesthesia,   hyperaesthesia, 


THE  PSYCHOGENIC  NEUROSES  465 

and  visual  disturbance;  globus  clavus,  singultus,  fainting 
fits,  loss  of  appetite,  obstinate  vomiting,  disturbance  of 
respiration,  and  anomalies  of  secretion.  Anaesthesia  of 
the  mucous  membrane  of  the  mouth  and  of  the  cornea  is 
regarded  as  a  characteristic  symptom  of  hysteria.  Finally, 
disorders  of  sleep  are  very  frequent.  It  is  characteristic  of 
all  these  symptoms  that  they  do  not  follow  anatomical  and 
physiological  rules,  but  are  dependent  in  their  appearance, 
persistence,  and  departure  upon  psychic  influences.  Hemi- 
crania  or  convulsive  movements  can  often  be  made  to  dis- 
appear by  pressure  upon  the  eyeballs.  Contractures  or 
paralyses  may  be  made  to  vanish  by  firm  pressure  over  the 
ovaries  or  in  the  hypogastric  region,  or  by  an  unexpected 
dash  of  cold  water  upon  the  face  or  body.  Patients  who 
for  years  have  been  bedridden,  reduced  to  a  skeleton  by 
fasting,  and  secretly  inflicting  wounds  upon  themselves  to 
incite  sympathy,  may  be  immediately  transformed  into  entirely 
different  individuals  by  a  sharp  command,  new  environment, 
or  some  sudden  freak.  But  such  transformations  are  usually 
short-lived,  and  the  patients  relapse  either  into  their  former, 
or  a  still  more  distressing,  condition.  Furthermore,  the 
symptoms  sometimes  disappear  when  the  patients  believe 
themselves  unobserved  or  are  left  alone,  only  to  reappear  as 
soon  as  their  illness  is  referred  to,  or  when  confronted  by  the 
physician. 

These  various  mental  and  physical  symptoms  just  described 
are  characteristic  of  the  hysterical  personality  and  constitute 
the  groundwork  upon  which  there  develop  other  characteristic 
transitory  hysterical  states. 

Of  these  transitory  hysterical  conditions,  the  befogged 
states  are  the  most  prominent.  They  are  characterized  by 
a  marked  clouding  of  consciousness,  of  varying  duration,  and 
either  follow,  take  the  place  of,  terminate  in,  or  are  interrupted 

2h 


466  FORMS  OF  MENTAL  DISEASE 

by,  a  convulsion.  In  the  simple  hysterical  attack  there  is, 
throughout  its  entire  course,  only  a  clouding  and  not  a  com- 
plete abolition  of  consciousness.  The  patients  usually  sink 
to  the  floor  without  injuring  themselves,  and  during  the 
attack  often  show  in  one  way  or  another  that  they  are  in- 
fluenced by  external  stimuli.  The  attack  may  consist  of 
simple  fainting,  or  may  be  accompanied  by  pronounced 
convulsive  movements.  The  convulsive  movements  do  not 
show  fixed  rigidity  or  uniform  trembling,  but  seem  more 
complicated  and  at  times  even  appear  purposeful.  The 
patients  twist  themselves  about,  groaning  and  screaming, 
they  roll  over  and  straighten  out,  strike  their  feet  on  the 
floor,  or  roll  themselves  up  like  a  ball;  at  the  same  time  there 
is  a  spasm  of  the  diaphragm,  marked  slowing  of  the  pulse, 
flushing  of  the  face,  and  rolling  of  the  eyes.  Very  often  the 
back  is  so  strongly  bent  that  the  patient's  body  rests  on  the 
bed  only  at  the  back  of  the  head  and  at  the  heels,  forming 
the  arc  of  a  circle.  At  intervals  the  patients  may  turn  somer- 
saults, or  suddenly  leap  up,  clutch  at  various  articles,  or  cling 
to  something;  they  may  also  make  grimaces.  Occasionally 
they  exhibit  delirious  states,  in  which  they  imagine  that  they 
are  passing  through  some  exciting  experiences  and  make 
all  sorts  of  active  movements.  Often  the  patients  repeat 
some  actual  occurrence  in  all  its  details,  but  usually  in  a 
theatrical  manner.  Sometimes  the  content  of  the  delirium 
is  wholly  fictitious,  when  the  patients  find  themselves  in 
some  fearful  predicament  or  a  state  of  ecstasy  with  heavenly 
visions  and  feelings  of  joy. 

All  of  these  different  symptoms  of  the  hysterical  attack 
may  succeed  each  other  in  various  ways.  Frequently,  they 
are  repeated  over  and  over  in  a  regular  order.  The  delirium 
may  be  interrupted  by  fainting  spells  or  convulsions.  Some- 
times the  physical  and  mental  symptoms  of  the  attack 


THE    PSYCHOGENIC  NEUROSES  467 

occur  separately,  and  at  other  times  combined  in  various 
ways. 

Following  the  attack,  the  patients  lie  quietly  with  relaxed 
limbs,  occasionally  showing  a  slight  tonic  rigidity,  breathing 
quietly,  and  with  a  slow  pulse  rate,  the  eyes  turned  upward 
or  rotated  laterally.  They  are  irresponsive,  except  to  a 
powerful  stimulus,  such  as  an  electric  shock  or  sudden  terror, 
which  sometimes  entirely  arouses  them.  Such  a  condition, 
interrupted  by  occasional  convulsions  and  short  lucid  inter- 
vals, during  which  food  can  be  taken,  may  last  from  a  few 
hours  to  three  weeks.  This  condition  has  been  termed  hys- 
terical lethargy. 

Sometimes  the  befogged  state  simulates  ordinary  sleep. 
The  patients  become  drowsy,  the  eyes  close,  the  limbs  be- 
come relaxed,  as  in  a  profound  sleep,  and  the  respiration  deep 
and  regular.  This  state  is  usually  of  short  duration,  and  the 
patients  awaken  gradually  with  no  recollection  of  the  inter- 
val, although  it  is  possible  to  arouse  them  by  means  of  a 
strong  stimulus,  when  they  rub  their  sleepy  eyes  and  look 
about  as  if  surprised. 

This  last  form  borders  closely  upon  somnambulism,  which 
occurs  during  the  natural  sleep  of  hysterical  patients.  The 
patients  leave  their  beds,  wander  about  the  room,  open  the 
window,  and  perform  many  peculiar  acts,  all  of  which  are 
well  coordinated.  Sometimes  they  destroy  clothing,  hide 
objects,  or  set  fire  to  furniture;  later  they  return  to  their  beds, 
and  arise  the  next  morning  with  only  a  confused  recollection 
of  what  has  happened.  Similar  attacks  may  occur  during 
the  daytime,  either  independently  or  in  connection  with  a 
convulsive  attack,  a  fit  of  laughing  or  crying.  The  patients 
then  walk  about,  muttering  unintelligibly  to  themselves, 
are  oblivious  to  the  environment,  and  not  the  least  distracti- 
ble,  although  able  to  avoid  obstacles.    It  is  very  difficult  to 


468  FORMS  OF  MENTAL  DISEASE 

arouse  them  from  this  state,  even  by  the  application  of  pow- 
erful electrical  currents. 

This  last  condition  is  perhaps  related  to  those  befogged 
states  with  inconsequential  speech,  which  have  been  described 
by  Ganser.  It  occurs  mostly  among  prisoners  awaiting  trial, 
who  suddenly  become  dazed,  suffer  fromactive  hallucinations, 
and  when  questioned  give  inconsequential  answers  in  spite 
of  the  fact  that  they  apparently  comprehend  the  questions, 
although  with  some  difficulty.  At  the  same  time  there 
exist  extensive  and  variable  areas  of  anaesthesia  to  pain. 
After  a  duration  of  a  few  days,  the  symptoms  disappear,  and 
the  patients  have  no  memory  of  the  psychosis.  In  a  few 
cases  a  series  of  these  befogged  states  may  extend  through 
several  months. 

Befogged  states  with  silly  excitement  are  encountered  in 
young  patients  in  whom  the  clouding  of  consciousness  is 
moderate,  and  does  not  prevent  a  recognition  of  their  en- 
vironment. Patients  usually  exhibit  a  happy,  unrestrained 
mood,  sometimes  with  marked  silly  behavior.  They  per- 
form all  sorts  of  foolish,  wanton  pranks,  scream,  imitate  the 
cries  and  behavior  of  animals,  and  scramble  about.  The 
real  morbidity  of  this  apparently  conscious  behavior  becomes 
evident  when,  as  occasionally  happens,  it  is  suddenly  termi- 
nated by  a  light  convulsive  seizure,  and  then,  without 
memory  of  the  foregoing  behavior,  the  patients  pass  into  a 
short  period  of  depression. 

The  memory  of  the  events  during  the  befogged  states,  as 
well  as  occasionally  for  events  just  prior  to  the  onset,  is 
always  much  disordered,  and  sometimes  completely  abol- 
ished. In  some  cases  there  are  encountered  examples  of  a 
sort  of  dual  personality,  in  which  the  recollection  of  previous 
attacks  occurs  only  during  subsequent  attacks,  being  com- 
pletely lost  in  the  interval.    It  occasionally  happens  during 


THE  PSYCHOGENIC  NEUROSES  469 

an  attack  that  some  definite  period  of  the  patient's  life  is 
lived  over  again,  similar  to  what  occurs  in  hypnotic  states. 
Such  alterations  in  personality  arise  only  under  the  influence 
of  autosuggestion. 

Nissl  finds  that  twelve  per  cent,  of  female  insane  patients 
suffering  from  various  psychoses  present  some  hysterical 
symptoms.  These  occur  especially  in  manic-depressive  in- 
sanity, and  also  in  the  early  stages  of  dementia.  But  in 
addition  to  this  there  occur  during  the  course  of  hysterical 
insanity  well-defined  mental  disturbances,  which  are  a  part 
of  the  hysterical  personality.  These  include  sad  and  anxious 
states  of  varying  duration  which  appear  independently  of 
any  sufficient  cause  and  are  accompanied  by  indefinite 
delusions  of  self-accusation  and  persecution.  The  patients 
may  also  speak  of  seeing  forms  and  hearing  threats,  but  it 
is  doubtful  if  these  are  genuine  hallucinations  or  are  really 
connected  with  dreams.  Conditions  of  excitement,  arising 
as  the  result  of  jealousy,  spite,  and  the  like,  more  frequently 
appear  in -the  form  of  passionate  outbreaks  with  violent 
abuse,  and  sometimes  a  tendency  to  destroy  objects,  or  even 
to  smear  their  bodies.  These  usually  pass  off  in  a  few  hours 
or  at  the  most  a  few  weeks.  Sometimes  they  recur  in  con- 
nection with  the  menses. 

Course.  — The  course  of  the  disease  is  usually  protracted, 
sometimes  extending  over  many  years.  In  women  espe- 
cially the  onset  of  the  disease  is  early,  frequently  appearing 
at  the  age  of  puberty,  but  it  may  occur  even  earlier.  The 
individual  symptoms  may  show  the  greatest  variation  in  their 
appearance  and  prominence;  indeed,  the  rapidity  and  abrupt- 
ness with  which  the  symptoms  change  is  distinctly  charac- 
teristic of  hysterical  insanity.  In  a  way  the  disease  may  be 
regarded  as  a  series  of  attacks  which  recur  on  the  basis  of 
the  hysterical  personality.    These  attacks  rarely  last  longer 


470  FORMS  OF  MENTAL  DISEASE 

than  a  few  months,  and  usually  do  not  exist  more  than 
a  few  days  or  even  hours.  But  the  different  depressed, 
excited,  and  befogged  states,  together  with  the  physical  dis- 
turbances, may  produce  a  variegated  and  incongruous  pic- 
ture extending  over  considerable  time.  The  course  of  the 
disease  in  children  is  characterized  by  less  variety  of  symp- 
toms and  a  shorter  duration,  while  in  males  there  is  a  far 
more  uniform  picture  with  little  variation  of  the  individual 
symptoms,  which  may  persist  unchanged  for  years. 

Diagnosis.  —  The  diagnosis  of  hysterical  insanity  is  most 
difficult  in  men.  The  constitutional  psychopathic  states  pre- 
sent a  more  uniform  course,  while  hysterical  befogged  states 
and  various  physical  symptoms  are  not  encountered.  In 
traumatic  neurosis  there  is  a  far  more  uniform  development. 
The  differentiation  from  epilepsy  has  received  sufficient 
consideration  under  that  disease.  Finally  there  may  be 
some  difficulty  in  differentiating  the  hysterical  befogged 
states  with  inconsequential  speech  from  catatonia,  in  which 
inconsequential  speech  is  frequently  encountered,  and  in 
which  the  areas  of  analgesia  may  be  mistaken  because 
of  the  presence  of  negativism.  In  catatonia  there  is  prac- 
tically no  clouding  of  consciousness. 

The  differentiation  of  hysterical  insanity  from  those 
psychoses  in  which  individual  hysterical  symptoms  some- 
times appear,  such  as  manic-depressive  insanity,  dementia 
praecox,  paresis,  etc.,  must  depend  wholly  upon  the  presence 
of  the  symptoms  which  are  characteristic  of  those  forms  of 
disease. 

Prognosis.  —  The  prognosis  of  hysterical  insanity,  as  re- 
gards the  befogged  states,  is,  in  general,  good;  sooner  or 
later,  either  with  or  without  treatment,  there  is  an  improve- 
ment or  at  least  a  considerable  change.  The  disease  in  itself 
does  not  progress.    The  improvement  or  aggravation  of  the 


THE  PSYCHOGENIC  NEUROSES  471 

symptoms  depends  very  materially  upon  the  peculiar  con- 
ditions in  which  the  patients  find  themselves.  At  any  rate 
dementia  never  develops.  The  prognosis  is  less  favorable 
where  there  is  an  increasing  tendency  to  relapses  into  the 
varied  forms  of  the  disease.  Hysteria  in  children  is  decidedly 
more  hopeful,  as  the  symptoms  usually  disappear  with  the 
development  of  the  child.  Occasionally,  remarkable  cures 
are  effected  by  the  removal  of  prominent  exciting  causes ;  as, 
diseases  of  the  sexual  organs,  injurious  environment,  and 
improper  hygiene.  In  male  patients  there  is  a  severe  form 
of  hysterical  insanity  with  pronounced  hypochondriacal 
complaints  which  is  resistive  to  all  modes  of  treatment. 

Treatment.  —  The  disease,  developing  as  it  does  upon  a 
psychopathic  basis,  demands  prophylaxis  in  the  way  of  care 
of  the  pregnant  mother,  and  careful  supervision  of  the  edu- 
cation and  training  of  psychopathic  children.  The  pregnant 
neurotic  mother  should  avoid  all  forms  of  excitement  and 
sources  of  fear  and  worry,  and  conform  as  closely  as  possible 
to  a  life  of  mental  equanimity.  The  child,  especially  if  it 
shows  a  tendency  to  insomnia,  with  night  terrors  or  restless- 
ness and  evidences  of  unnatural  excitability  and  precocity, 
must  be  removed  from  the  presence  of  a  hysterical  mother, 
who  is  naturally  least  fitted  for  its  training.  Such  pernicious 
environment,  where  the  child  must  witness  emotional  out- 
bursts and  fits  of  temper  and  other  hysterical  symptoms, 
has  an  indelible  effect,  particularly  in  the  formative  period 
between  the  fifth  and  twelfth  years. 

Relieved  of  such  surroundings,  the  main  object  in  the 
education  should  be  the  development  of  physical  strength 
and  vigor,  and  the  maintenance  of  an  effective  state  of 
nutrition.  For  this  purpose,  plenty  of  out-of-door  exer- 
cise, with  an  abundance  of  sleep  and  wholesome  diet,  must 
be  prescribed  in  connection  with  a  discouragement  of  all 


472  FORMS  OF  MENTAL  DISEASE 

elements  of  precocity  in  the  mental,  moral,  and  sexual 
life,  and  inculcation  of  self-control  and  the  nobler  senti- 
ments. The  same  care  must  be  continued  during  the 
period  of  puberty  and  youth,  but  should  include  advice 
in  relation  to  sexual  matters,  sentimental  love  affairs,  and 
later  relative  to  the  assumption  of  the  duties  of  early  mar- 
ried life,  especially  sexual  relations. 

In  the  treatment  of  the  disease  itself  the  element  most 
essential  to  success  lies  in  the  personality  of  the  physician, 
who  must  inspire  the  patient  with  confidence  and  secure 
the  cooperation  of  the  family.  Except  in  the  lighter 
cases,  it  is  of  first  importance  to  isolate  the  patients  and 
establish  a  suitable  routine  in  the  mental  and  physical 
fife,  thereby  removing  from  the  environment  the  disturb- 
ing factors  which  have  always  been  a  source  of  annoyance 
and  have  acted  as  exciting  causes.  This  isolation,  although 
best  carried  out  in  a  small,  well-selected  sanitarium,  under 
the  direct  supervision  of  a  physician,  can  be  accomplished, 
with  the  aid  of  an  efficient  nurse,  at  the  home.  At  all  events 
the  patient  must  be  given  over  entirely  into  the  hands  of 
the  physician,  who  establishes  confidence  and  control,  not 
by  harsh  and  dogmatic  opposition,  but  by  gentle  persistence, 
in  which  he  must  combine  firmness  and  even  boldness.  This 
accomplished,  he  is  in  a  position  to  bring  about  great  im- 
provement, and  often  recovery,  by  simple  remedies.  Atten- 
tion should  be  directed  to  any  possible  organic  disturbances 
in  the  stomach,  intestines,  kidneys,  heart,  lungs,  and  sexual 
organs.  Iron  should  be  prescribed  in  anemia,  and  restora- 
tives employed  in  conditions  of  emaciation,  as  well  as  bitter 
tonics  for  anorexia. 

On  the  other  hand,  mechanical  therapy  can  be  relied 
upon  to  produce  excellent  results.  Of  the  mechanical 
measures  the  most  important  are  hydrotherapy,  electricity, 


THE  PSYCHOGENIC  NEUROSES  473 

massage,  exercise,  and  employment.  In  the  use  of  hydro- 
therapy Collins  regards  the  tonic  bath  the  best,  in  which 
the  water,  at  a  temperature  varying  from  fifty-five  to  sixty 
degrees,  is  applied  under  from  fifteen  to  twenty  pounds' 
pressure  for  from  four  to  five  seconds,  followed  by  a  Fleury 
spray  of  eighty  degrees  and  similar  pressure  for  one  to 
two  seconds.  In  the  use  of  the  bath  hysterogenic  zones 
must  be  protected.  The  reaction  should  be  facilitated  by 
passive  movements,  walking,  or  gymnastics,  for  one  half- 
hour  following  the  bath.  Where  this  bath  fails  to  pro- 
duce the  desired  effect  or  is  not  well  borne,  he  suggests 
the  use  of  the  Scottish  spray.  It  is  always  desirable,  when 
possible,  to  avail  oneself  of  a  hydriatic  institution  for  these 
purposes.  The  treatment  can  be  accomplished,  however, 
in  a  house  supplied  with  water  under  sufficiently  high 
pressure  by  the  simple  use  of  a  detachable  hose  and  a  tube. 
This  should  always  be  under  the  direct  supervision  of  the 
physician,  who  will  find  it  necessary  to  vary  the  details  of 
the  treatment  according  to  individual  cases.  When  the 
bath  is  not  accessible,  the  drip  sheet  may  be  used,  the  descrip- 
tion of  which  may  be  found  under  the  treatment  of  acquired 
neurasthenia. 

In  the  application  of  electricity  the  faradic  current  is  of 
most  service  in  improving  the  nutrition  and  in  relieving 
anaesthesia  and  hypersesthesia. 

The  daily  routine  of  the  hysterical  patient  should  be  one 
of  activity,  alternating  with  rest  and  relaxation,  including 
massage,  gymnastics,  and  out-of-door  exercise,  combined 
with  some  sport  which  tends  to  increase  self-reliance. 

There  are  a  few  cases  which  require  surgical  treatment 
for  the  alleviation  of  organic  disturbances  in  the  sexual 
organs,  especially  where  the  symptoms  of  the  disease  seem 
to  bear  a  definite  relation  to  the  menstruation.    Removal 


474  FORMS  OF  MENTAL  DISEASE 

of  slightly  diseased  or  even  normal  ovaries  has  produced 
improvement  in  a  few  cases,  but  it  is  the  general  verdict  of 
to-day  that  this  drastic  procedure  has  more  often  been  of 
detriment  than  benefit,  and  should  be  discarded.1 

Hypnotism  is  of  limited  value,  because  those  suscep- 
tible to  hypnotic  suggestion  are  apt  to  be  influenced  by  any 
powerful  suggestion  that  happens  to  be  presented.  Fur- 
thermore, hypnotic  experience  brings  about  an  undesirable 
dependency  of  the  patient  upon  the  physician,  which  makes 
impossible  an  effective  subjugation  of  their  own  wills  in  the 
strife  with  the  morbid  influences.  The  greater  the  influence 
exerted,  the  more  easily  autosuggestions  arise,  and  the 
quicker  the  efficacy  of  the  hypnotic  suggestion  is  nullified 
by  other  and  opposing  ideas.  In  mild  cases,  and  especially 
in  children,  suggestive  therapy  is  of  considerable  importance 
in  overcoming  individual  hysterical  symptoms,  such  as 
paralyses,  sensory  disturbances,  and  tremor.  On  the  other 
hand,  simple  suggestion  is  a  therapeutic  measure  of  great 
value  in  every  case,  and  often  suffices  for  the  complete  dis- 
appearance of  paralyses,  contractures,  aphonia,  etc. 

In  the  treatment  of  the  hysterical  attacks,  the  patient 
can  often  be  restored  to  clear  consciousness  by  a  brisk 
command,  or,  if  this  fails,  by  a  dash  of  cold  water  upon  the 
face,  by  the  electric  brush,  or  pressure  over  the  ovaries 
or  upon  the  hysterogenic  zones.  In  very  severe  cases  in- 
halations of  chloroform  may  be  necessary. 

1  Angelucci,  e  Pieracini,  Rivista  sperimentale  di  freniatria,  XXIII,  290. 


THE  PSYCHOGENIC  NEUROSES  475 

B.  Traumatic  Neurosis1 
(Traumatic  Hysteria) 

Traumatic  neurosis  arises  as  the  result  of  trauma  and 
is  characterized  by  the  gradual  appearance  of  a  prolonged 
period  of  mental  depression  accompanied  by  numerous  motor 
and  sensory  nervous  symptoms.  The  trauma  may  occur  in 
the  form  of  sudden  fright,  intense  anxiety,  great  misfortune, 
or  an  injury  in  connection  with  a  fire,  railroad  accident, 
explosion,  earthquake,  sunstroke,  or  electrical  shock. 

Cases  of  this  sort  were  first  recognized  and  well  described 
by  Erichsen  in  1886,  but  it  was  not  until  the  investigation  of 
Oppenheim  and  Striimpell  in  1889  that  the  disease  was 
clearly  differentiated  and  received  its  present  name.  The 
recognition  of  such  a  disease  has  always  met  with  more  or 
less  opposition,  especially  by  French  writers,  and  more 
recently  from  Schultze,  Hoffman,  and  Mendel,  who  maintain 
that  the  disease  is  either  hysteria  or  neurasthenia  of  trau- 
matic origin. 

Etiology.  —  At  present  there  is  no  adequate  explanation  of 
the  pathology  of  the  disease.  Westphal  and  his  school  con- 
sider that  there  is  an  organic  basis  to  be  found  in  changes 
of  the  central  nervous  system.  Charcot  regards  the  disease 
as  closely  related  to  the  hypnotic  condition,  because  the 

1  Oppenheim,  Die  traumatischen  Neurosen,  2.  Auflage,  1892;  Schultze, 
Sammlung  klinischer  Vortrage,  N.  F.,  14  (Innere  Medicin,  No.  6) ;  Deut- 
sche Zeitschr.  f.  Nervenheilkunde,  I,  5.  u.  6,  445;  Strumpell,  Miinch- 
ner  Medicinische  Wochenschrift,  1895,  49  u.  50;  Sanger,  Die  Beurteilung 
der  Nervenerkrankungen  nach  Unfall,  1896;  Fiirstner,  Monatsschr. 
f.  Unfallheilkunde,  1896,  10;  Schuster,  Die  Untersuchung  und  Begut- 
achtung  bei  traumatischen  Erkrankungen  des  Nervensystems,  1899; 
Sachs  und  Freund,  Die  Erkrankungen  des  Nervensystems  nach  Unfallen 
mit  besonderer  Beriichsichtigung  der  Untersuchung  und  Begutachtung, 
1899;  Bruns,  Die  traumatischen  Neurosen.  Unfallsneurosen,  Nothna- 
gels  Handbuch,  XII,  1,  4,  1901. 


476  FORMS  OF  MENTAL  DISEASE 

disease  picture  wholly  resembles  the  picture  of  a  firmly 
rooted  autosuggestion.  The  psychical  origin  of  the  disease 
is  the  generally  accepted  view.  This  theory  is  substantiated 
by  the  facts  that  the  neurosis  sometimes  appears  without 
known  injury,  as  when  it  follows  fright  or  slight  injury  to 
other  parts  of  the  body  than  upon  the  head;  and  that  the 
manifestations  of  the  disease  are  not  necessarily  limited  to 
the  part  where  the  injury  occurs,  but  may  be  general.  In 
cases  following  head  injury  it  is  held  that  delicate  patho- 
logical changes  occur  in  the  cortical  neurones.  Experi- 
mentation upon  test  animals,  in  which  definite  pathological 
lesions  in  the  neurones  can  be  produced  by  concussion  with- 
out severe  injury,  would  seem  to  verify  this  supposition. 

It  is  doubtful  whether  the  emotional  disturbance  at  the 
time  of  the  accident  should  be  regarded  as  the  cause  of  the 
disease,  as  very  frequently  weeks  and  even  months  elapse 
before  the  first  symptoms  appear.  An  important  factor, 
undoubtedly,  is  the  psychical  influence  of  membership  in 
accident  insurance  societies,  of  possible  indemnities,  and  of 
suits  for  damages.  At  any  rate,  in  cases  where  these  factors 
exist,  the  neurosis  seems  to  run  a  more  unfavorable  course. 
The  symptoms  regularly  worsen  until  settlement  is  reached, 
when  they  are  apt  to  improve  rapidly  and  often  entirely 
disappear.  Another  element  of  importance  is  the  defective 
constitutional  basis,  in  which  alcoholic  intemperance  plays 
a  considerable  role. 

Symptomatology.  —  The  symptoms  develop  gradually 
in  the  course  of  a  few  weeks  or  months  following  the  shock, 
and  consist  chiefly  of  despondency  with  anxious  fears  and  loss 
of  the  power  of  physical  and  mental  resistance,  and  an  in- 
capacity for  any  earnest  employment. 

Patients  seem  quiet  and  low  spirited.  Apprehension 
is  slow,  and  they  take  less  and  less  interest  in  the  environ- 


THE  PSYCHOGENIC  NEUROSES  477 

ment.  The  association  of  ideas  becomes  unusually  uniform 
and  sluggish,  and  centers  mostly  about  the  accident,  to  which 
the  patients  refer  over  and  over  and  often  describe  in 
detail,  laying  stress  upon  their  "  hard  luck,"  present  deplor- 
able condition,  and  hopeless  future.  Sometimes  com- 
pulsive ideas  and  phobias  appear.  Hypochondriacal  ideas 
become  very  prominent.  Patients  cannot  rid  themselves 
of  thoughts  of  the  accident  and  fear  that  they  have  been 
severely  injured,  because  they  are  not  the  same,  are  always 
tired,  exhausted,  and  unable  to  work.  They  observe  care- 
fully everything  about  their  physical  condition  connected 
with  the  injury. 

In  emotional  attitude  patients  are  very  irritable,  sensitive, 
and  easily  thrown  into  a  state  of  perplexity  or  confusion, 
are  unable  to  express  themselves  with  perfect  coherence, 
and  are  conscious  that  their  thoughts  and  actions  are  con- 
stantly hindered  by  feelings  of  inward  oppression  and 
anxiety.  This  anxiety  may  lead  to  passionate  outbursts 
and  even  suicidal  attempts.  Memory,  in  spite  of  complaints 
to  the  contrary,  is  good,  if  one  makes  allowance  for  the  lack 
of  interest  in  the  environment  and  the  faulty  attention. 
When  agitated,  the  patients  may  not  be  able  to  solve  even 
simple  problems.  Their  capacity  for  work  is  greatly  ham- 
pered by  hypochondriacal  notions  and  numerous  nervous 
complaints.  Whenever  they  attempt  to  do  something, 
headache,  palpitation  of  the  heart,  excessive  perspiration, 
etc.,  develop. 

The  mental  symptoms  usually  do  not  progress.  Oc- 
casionally befogged  states  or  an  acute  hallucinatory  excite- 
ment appears.  If  mental  impairment  develops,  it  is  usually 
due  to  a  cerebral  lesion. 

Physical  Symptoms.  —  Sleep  is  disturbed  by  anxious 
dreams,  the  appetite  is  poor,  and  nutrition  becomes  impaired. 


478  FORMS  OF  MENTAL  DISEASE 

Patients  complain  of  various  sensations  in  the  head  and 
back,  especially  paresthesias  and  pains  in  parts  of  the  body 
injured  at  the  time  of  the  accident.  Pain,  which  is  usually 
the  most  prominent  symptom,  is  persistent  and  troublesome 
and  may  lead  to  immobility  of  the  parts  involved.  In  addi- 
tion, patients  complain  of  ringing  in  the  ears,  loss  of  strength, 
palpitation  of  the  heart,  difficulty  of  urination,  and  occasion- 
ally obstinate  vomiting.  Some  cases  present  objective 
symptoms,  such  as  areas  of  analgesia  and  of  hyperesthesia, 
constriction  of  the  field  of  vision,  difficulty  of  hearing, 
increased  tendon  reflexes,  paralyses,  slowness  and  uncer- 
tainty of  movement,  and  disturbance  of  gait  and  speech. 
Tremor,  especially  of  the  fibrillary  type,  is  often  present, 
being  either  general  in  character  or  involving  only  muscles 
of  the  paralyzed  part.  Paralysis  may  occur  in  the  form  of 
hemiplegia  or  paraplegia,  but  the  facial  and  hypoglossal 
nerves  are  seldom  included.  The  paralysis  almost  always 
occurs  on  the  same  side  as  the  accident,  and  is  frequently 
accompanied  by  contractures.  There  is  often  an  accelera- 
tion of  pulse  and  sometimes  of  respiration  following  emotional 
disturbance,  pressure  on  the  painful  points,  or  muscular 
exertion.  Occasionally,  also,  vertigo  or  even  epileptiform 
attacks  may  be  produced  in  the  same  way.  Localized 
muscular  spasms  and  convulsions  are  common.  Vaso- 
motor disturbances  occur,  as  localized  blushing,  cyanosis, 
and  dermography.  Sensory  disturbances,  both  subjective 
and  objective,  of  which  hyperesthesia  is  most  prominent, 
usually  involve  the  injured  side  of  the  body. 

All  of  the  motor  and  sensory  nervous  disturbances  are  to  be 
distinguished  from  those  accompanying  organic  brain  and 
cord  lesions  by  their  location,  their  broad  extent,  changing 
condition,  and  the  fact  that  they  worsen  under  the  influence 
of  emotional  and  physical  disturbances.     Friedmann  adds 


THE  PSYCHOGENIC  NEUROSES  479 

that  these  patients  have  little  power  of  resistance  to  alcohol, 
galvanization  of  the  head,  and  compression  of  the  carotids. 

Diagnosis.  —  The  diagnosis  is  often  very  difficult.  Hys- 
terical insanity  is  distinguished  by  the  lack  of  uniformity  of 
the  symptoms  in  a  given  case;  the  hysterical  patients  pre- 
sent a  variegated  and  transitory  alteration  of  symptoms, 
capriciousness,  pronounced  changes  of  disposition,  desire 
for  undertaking  something  new,  and  great  pliancy.  Further- 
more, traumatic  neurosis  does  not  present  befogged  states. 
The  constitutional  psychopathic  states  are  differentiated  by 
the  fact  that  the  onset  is  not  sudden,  does  not  depend  upon 
an  injury,  and  has  a  less  favorable  course. 

Simulation  should  always  be  taken  into  consideration. 
Unfortunately  the  various  objective  symptoms,  constricted 
field  of  vision,  acceleration  of  pulse,  increased  tendon 
reflexes,  and  absence  of  galvanic  excitability,  are  of  little 
value  in  establishing  a  positive  knowledge  of  the  existence  of 
a  mental  disorder.  Deception  cannot  be  unmasked  by  the 
presence  or  absence  of  any  one  symptom  or  group  of  symp- 
toms, but  must  depend  upon  the  conformity  of  the  whole 
clinical  picture  to  one  of  the  known  disease-symptom  groups. 
Recently  psychological  tests  have  been  successfully  employed 
to  prove  the  mental  symptoms;  as,  for  example,  psychological 
tests  of  the  power  of  apperception,  test  of  diminution  of  the 
ability  to  figure,  the  susceptibility  to  training,  and  especially 
fatigue.  Thus  it  has  been  shown  that  in  traumatic  neurosis 
there  should  be  a  marked  loss  in  the  capacity  for  work 
and  a  very  great  increase  in  the  susceptibility  to  fatigue. 

Prognosis.  —  The  lighter  cases  of  traumatic  neurosis  ap- 
pearing soon  after  the  accident  may  improve  rapidly,  but 
even  some  of  these  run  a  long  course  and  have  an  unfavor- 
able outcome.  Yet,  after  a  duration  of  many  months  or 
even  a  few  years,  the  disease  may  terminate  in  recovery  or 


480  FORMS  OF  MENTAL  DISEASE 

great  improvement.  The  prognosis  is  less  favorable  in 
the  presence  of  pronounced  focal  symptoms  or  general 
arteriosclerosis. 

Treatment.  —  The  first  indication  is  to  dispel  as  far  as 
possible  all  ideas  of  litigation.  Next  to  this,  employment 
is  of  the  greatest  value.  It  often  happens  that  the  symptoms 
of  the  disease  disappear  rapidly  as  soon  as  litigation  is 
settled  or  patients  are  compelled  to  go  to  work  again.  A 
residence  in  an  institution  with  the  opportunity  for  employ- 
ment and  distraction  frequently  serves  to  bring  about  great 
improvement  or  recovery.  In  all  cases  hydrotherapy,  mas- 
sage, exercise,  electricity,  and  hypnotic  suggestion,  as  well 
as  dietetic  regimen,  are  of  value. 

C.    Dread  Neurosis 

The  dread  neurosis  comprises  a  small  group  of  neu- 
rotic cases  in  which  the  patients  suffer  from  a  more  or  less 
constant  feeling  of  anxious  suspense  which  dominates  the 
entire  life. 

The  conditions  about  which  the  anxiety  develop  are 
usually  processes  that  normally  take  place  without  conscious 
interference,  such  as  walking,  standing,  drinking,  writing, 
etc.  The  anxiety  almost  always  appears  for  the  first  time 
immediately  following  some  real  but  trifling  condition,  such 
as  an  experience  during  which  the  eyes  have  been  subjected 
to  fatigue  or  a  dazzling  light,  moderate  overexertion, 
fatigue  after  a  long  walk,  etc.  Anxiety  about  sleep  may 
follow  periods  of  emotional  stress.  Frequently  some 
physical  disease  initiates  some  of  the  symptoms :  a  feeling 
of  weakness  follows  a  mild  rheumatic  attack,  or  pain  in  the 
leg  follows  a  fall.  In  addition  to  feelings  of  anxiety  there 
regularly  develop  uncomfortable  and  even  painful  sensations, 
as  well  as  a  sort  of  paralytic  weakness  which  interferes  with 


THE  PSYCHOGENIC  NEUROSES  481 

the  movements.  The  painful  sensations,  especially,  accom- 
pany the  process  of  apprehension,  while  the  muscular 
weakness  appears  during  exertion  of  the  will,  though  both 
occur  together.  The  anxiety  and  the  accompanying  sensa- 
tions usually  occur  first  in  connection  with  some  simple 
act,  such  as  eating  certain  kinds  of  food,  reading  in  bright 
sunlight,  or  sleeping  in  a  certain  place.  But  they  gradually 
become  more  extensive  and  may  finally  render  some  particu- 
lar acts  wholly  impossible.  In  one  patient  insomnia  first 
developed  whenever  she  anticipated  doing  something  un- 
usual the  next  day,  such  as  going  to  the  city,  but  later  the 
most  trifling  affairs  would  cause  it  to  appear. 

The  clinical  picture  is  variegated;  while  patients  are 
reading,  letters  will  disappear,  then  there  is  a  feeling  of  heat, 
a  sensation  of  tension,  photophobia,  and  pains  that  streak 
across  the  forehead,  which  ultimately  compel  them  to  cease 
reading  altogether.  Similar  disturbances  develop  in  con- 
nection with  hearing.  In  writing  the  fingers  soon  stiffen, 
or  there  is  great  weakness.  Swallowing  can  be  rendered 
difficult  by  the  appearance  of  a  cramp  in  the  throat.  Walk- 
ing is  hindered  by  weakness  in  the  legs,  pains,  etc.  Sleep 
may  be  impaired  by  an  increasing  restlessness,  twitching  of 
the  limbs,  and  palpitation.  Some  cases  of  psychical  impo- 
tency  belong  here. 

Patients  mistake  the  true  origin  of  the  disorder  and  begin 
to  refer  it  to  real  diseases  of  the  eyes,  ears,  muscles,  and  nerves. 
This  causes  them  still  greater  anxiety,  and  undermines 
their  self-confidence.  Attention  is  directed  more  and  more 
to  these  supposed  physical  disorders,  and  thus  there  de- 
velops a  vicious  circle,  each  factor  adding  fuel  to  the  other 
and  making  it  impossible  for  the  patients  to  free  themselves. 
Increasing  sensitiveness  of  the  eyes  causes  the  patients  to 
systematically  avoid  light,  therefore  they  do  not  venture  out 

2i 


482  FORMS  OF  MENTAL  DISEASE 

save  at  twilight  or  on  cloudy  days.  Pain  and  weakness, 
which  interfere  with  walking  and  standing,  cause  the  patients 
to  gradually  limit  their  movements  and  ultimately  to  remain 
in  bed  altogether.  In  this  state  both  active  and  passive 
movements  may  produce  excruciating  pain.  Speech  and 
movements  of  the  head  are  singularly  free.  Furthermore, 
the  disorder  ordinarily  does  not  extend  into  other  fields, 
but  confines  itself  to  the  particular  process  which  was 
originally  involved,  as,  for  instance,  to  sight  or  to  walking. 

Consciousness  remains  clear ;  patients  are  oriented,  orderly, 
and  do  not  exhibit  emotional  deterioration.  They  com- 
placently endure  the  severe  suffering  which  they  regard 
as  purely  physical.  Hysterical  symptoms  are  never  a  part 
of  the  disease  picture. 

Course.  —  The  course  of  the  disease  is  usually  protracted, 
though  there  are  frequent  remissions.  Efforts  upon  the 
part  of  the  patients  to  overcome  their  symptoms  only  ag- 
gravate the  condition.  Strenuous  efforts  to  relieve  the 
patients  by  various  mechanical  and  medicinal  devices 
usually  effect  only  a  transitory  improvement.  On  the  other 
hand,  many  of  the  patients  get  well  of  their  own  accord. 

Diagnosis.  —  There  is  some  question  as  to  the  clinical 
position  of  the  dread  neurosis;  indeed,  the  fighter  forms 
have  often  been  considered  as  cases  of  nervousness  or 
neurasthenia,  while  Janet  describes  many  such  cases  under 
psychasthenia. 

Against  the  former  view  may  be  cited  the  fact  that  the 
patients  need  not  at  any  time  exhibit  any  other  nervous 
symptoms,  while  there  is  at  no  time  any  evidence  of  ner- 
vous exhaustion.  Although  the  symptoms  may  originate 
in  some  physical  ailment,  they  do  not  disappear  with  the 
recovery  from  that  condition  and  restoration  of  strength. 
The  differentiation  of  hysterical  insanity  depends  upon  the 


THE  PSYCHOGENIC  NEUROSES  483 

presence  of  the  unconscious  influencing  of  the  physical 
processes  through  emotional  excitation,  while  in  the  dread 
neurosis  it  is  alone  the  condition  of  weakness  and  instability 
which  deprives  the  patients  of  their  ability  to  withstand 
the  supposed  physical  affliction.  In  hysteria  the  symptoms 
frequently  alternate  from  one  field  to  another,  but  in  the 
dread  neurosis  the  symptoms  are  uniform  and  progressive. 

The  phobias  are  distinguished  from  this  disease  by  the 
fact  that  the  fears  are  more  general  in  character,  while 
in  this  disease  there  is  some  definite  personal  experience 
which  forms  the  starting-point.  In  the  phobias  the  fears 
frequently  change  in  several  different  directions,  but  in  the 
dread  neurosis  fear  is  uniform,  always  hypochondriacal, 
and  has  to  do  only  with  the  patients'  own  bodies.  Further- 
more, in  the  phobias  there  are  real  states  of  anxiety  which 
embarrass  the  patients  or  force  them  to  secure  protective 
measures,  but  in  this  disease  the  patients  are  not  conscious 
of  the  origin  of  their  difficulties,  which  appear  to  them  as 
real  pain,  actual  weakness,  or  genuine  ataxia. 

Treatment.  —  Many  patients  recover  of  themselves,  with- 
out any  treatment.  In  some  way  or  other,  frequently 
through  the  influence  of  some  one  whom  they  trust,  they 
regain  self-confidence  and  with  it  the  strength  to  conquer 
the  disease.  On  the  other  hand  there  are  many  cases  in 
which  failure  at  the  first  trial  destroys  all  hope  of  recovery. 
Patients  at  first  seem  to  react  well  to  new  methods  of  treat- 
ment, but  in  reality  from  the  very  beginning  they  are  apt 
to  cherish  a  vague  fear  that  they  cannot  recover.  Simple 
hypnotic  treatment  often  effects  a  rapid  and  permanent 
recovery.  Cases  of  even  ten  years'  standing  have  been  re- 
stored in  this  way.  This  form  of  treatment,  however,  is 
often  difficult,  and  demands  that  one  should  thoroughly 
understand  the  technique,  in  order  to  gain  the  confidence  of 


484  FORMS  OF  MENTAL  DISEASE 

the  patient,  without  which  success  is  impossible.  In  severe 
cases  it  is  often  necessary  to  begin  by  giving  only  quieting 
suggestions,  because  premature  suggestions  as  to  the  cure 
might  prove  disastrous.  This  method  rarely  fails.  In  case 
it  does,  one  may  employ  waking  suggestion,  but  its  influence 
is  not  as  effective.    Failing  in  this,  there  is  no  hope  for  cure. 


XIII.   CONSTITUTIONAL  PYSCHOPATHIC  STATES 

(Insanity  of  Degeneracy) 

The  fundamental  symptom  in  the  constitutional  psy- 
chopathic states  is  the  continuous  morbid  elaboration  of 
normal  stimuli  as  manifested  in  a  morbid  misdirection  of 
thought,  feeling,  and  will  throughout  life.  These  states 
develop  on  a  morbid  constitutional  basis.  The  commonest 
type  of  psychopathic  degeneracy  is  characterized  by  those 
little  imperfections  of  the  individual  constitution  which 
we  ordinarily  designate  as  nervousness.  These  symptoms 
form  the  groundwork  upon  which  the  more  marked  forms 
of  the  insanity  of  degeneracy  develop.  These  various  forms 
of  the  insanity  of  degeneracy  are  hard  to  group,  because 
there  are  so  many  combinations  and  border-line  states.  In 
the  present  state  of  our  knowledge  the  best  arrangement 
seems  to  be  constitutional  despondency,  constitutional  excite- 
ment, compulsive  insanity,  impulsive  insanity,  and  contrary 
sexual  instincts. 

A .   Nervousn  ess  * 

Nervousness  comprises  several  congenital  morbid  mental 
states  which  are  characterized  in  general  by  an   inability  to 

1  Saury,  Etude  clinique  sur  la  folie  hereditaire  (les  degeneres),  1886 ; 
Koch,  Die  psychopathischen  Minderwertigkeiten,  1893  ;  Binswanger,  Die 
Pathologie  und  Therapie  der  Neurasthenie,  1896;  v.  Krafft-Ebing, 
Nervositat  und  neurasthenische  Zustande,  2.  Auflage,  1900;  Gilles  de 
la  Tourette,  Les  etats  neurastheniques,  1898 ;  Janet,  Les  obsessions  et  la 
psychasthenie,  2.  Bande,  1903. 

485 


486  FORMS  OF  MENTAL  DISEASE 

ivithstand  the  misfortunes  of  life,  together  with  a  lack  of  sym- 
metry in  the  development  of  the  entire  'psychical  person- 
ality. 

Intellectual  endowment  usually  is  not  equal  to  the  average, 
although  occasionally  it  may  be  excellent.  Some  particular 
faculty  may  be  unusually  well  developed ;  as,  for  instance,  the 
sense  of  form,  of  color,  or  memory  for  numbers.  Some 
patients  may  be  able  to  perceive  keenly,  but  yet  lack  in- 
sight into  character,  or  may  possess  profound  knowledge 
without  any  practical  bent.  Some  patients  are  remarkably 
precocious. 

Increased  susceptibility  to  fatigue  is  a  prominent  symptom. 
Hence  patients  tire  quickly  and  have  little  endurance.  Oc- 
casionally they  learn  with  difficulty  and  quickly  forget  what 
they  have  learned.  Attention  shows  an  increased  distract i- 
bility.  Patients  are  very  sensitive  to  interruption,  and  are 
easily  distracted  from  their  customary  ideas  and  plans  by 
anything  new.  These  symptoms  give  rise  to  flightiness  and 
superficiality.  An  unusual  activity  of  the  imagination 
is  often  present.  Ideas  possess  a  great  sensory  vividness  and 
are  easily  united.  Consequently  there  develops  a  strong 
tendency  to  revery,  which  is  also  favored  by  the  distracti- 
bility  of  the  attention. 

While  egotism  usually  prevails,  on  the  other  hand,  self- 
depreciation  and  a  lack  of  self-confidence  may  be  present. 
Most  patients  lack  the  sense  of  reality.  To  them  the  daily 
occurrences  of  the  immediate  environment  seem  distant ; 
they  have  a  "  far-away  feeling  "  ;  indeed,  things  do  not  con- 
cern them  any  more  than  if  they  lived  in  another  world. 
Deceitfulness  is  also  a  common  symptom,  arising  in  part 
from  the  tendency  of  patients  to  busy  themselves  with  the 
products  of  their  own  imagination.  Superficial  recollections 
are  easily  falsified  by  the  addition  of  fictitious  facts,  even 


CONSTITUTIONAL   PSYCHOPATHIC  STATES  487 

without  the  patients  being  conscious  of  it.  Furthermore, 
the  emotional  states  exert  a  great  influence  over  the  ideas; 
hopes  and  fears  guide  the  thoughts,  while  vivid  impressions 
as  well  as  accidental  ideas  dominate  intuition  and  recollec- 
tions. 

In  the  emotional  field  there  is  a  tendency  to  asymmetrical 
development.  Great  sensitiveness,  eagerness,  and  excessive 
enthusiasm  may  predominate,  while  the  more  natural  feel- 
ings are  arrested.  In  connection  with  an  artistic  sense  of 
appreciation  there  may  be  a  lack  of  tact  or  a  moral 
obtuseness.  Unnatural  affections  arise;  for  instance,  a 
fanatic  affection  for  one  of  the  animals,  an  idolatrous  adora- 
tion of  some  person,  also  numerous  idiosyncrasies,  or  a 
senseless  abhorrence  or  fear  of  certain  persons,  objects,  or 
disease  symptoms.  There  are  many  striking  peculiarities 
of  the  emotional  attitude, —  morbid  tender-heartedness, 
extravagances,  or  persistent  timidity  and  cowardice.  Rapid 
and  sudden  changes  of  the  emotional  attitude  are  frequent : 
exuberant  happiness  suddenly  changes  to  seclusiveness  or 
outbursts  of  fury;  patients  become  excessively  angry  and 
just  as  quickly  placid. 

In  accord  with  the  feeling  of  egoism,  the  patients  attend 
chiefly  to  their  own  thoughts  and  busy  themselves  with 
their  own  welfare.  Thus  they  observe  in  a  most  painstaking 
manner  the  minor  physical  changes,  which  then  rapidly 
multiply  and  cause  apprehension.  Constant  thought  of  self 
and  superficiality  of  the  feelings  gradually  leads  to  selfish- 
ness. Patients  are  cold,  unapproachable,  associate  with  no 
one,  and  are  most  inconsiderate  of  nearest  relatives.  They 
degrade  themselves  in  numerous  ways  in  an  effort  to  arouse 
special  recognition  and  sympathy. 

The  actions  of  the  patients  show  constant  constraint. 
Voluntary  impulses  do  not  arise  from  established  principles, 


488  FORMS  OF  MENTAL  DISEASE 

but  from  momentary  feelings  and  impulses,  as  well  as  through 
accidental  impressions.  Fears  and  passionate  impulses 
interfere  with  a  harmonious  development  and  release  of 
voluntary  action.  Hence  patients  are  never  able  to  follow 
anything  to  its  conclusion,  as  is  clearly  indicated  in  their 
occasional  foolish  and  weak  attempts  at  suicide,  showing 
an  inability  to  transform  their  desperate  feelings  into  reso- 
lute acts. 

The  patients  themselves  usually  feel  their  inability  to 
do  satisfactory  and  uniform  work.  If  at  the  outset 
they  seek  to  become  masters  of  their  own  imperfections 
by  means  of  a  strong  exertion  of  the  will,  they  gradually 
lose  ground.  A  constant  struggle  regularly  leads  to  weari- 
ness and  enervation.  Many  patients  gradually  withdraw 
from  any  serious  activity  and  let  things  go  as  they  will. 
Impulsive  acts,  foolish  journeys,  precipitate  betrothals, 
changes  of  location  and  profession,  and  attempts  at  suicide 
are  constantly  occurring. 

Impulsiveness  becomes  more  and  more  prominent,  and 
certain  habits  of  will  often  develop  which  are  exceedingly 
difficult  to  break  up.  Patients  must  conduct  their  business 
always  in  a  certain  way,  and  at  once  become  embarrassed  and 
ill  at  ease  as  soon  as  a  change  takes  place.  They  are  apt  to 
fall  an  easy  prey  to  the  misuse  of  drugs,  become  drunkards, 
drink  strong  tea  and  coffee,  and  are  frequently  given  to 
excessive  dosing  with  quack  remedies. 

The  sexual  life  is  usually  an  important  factor.  Sexual 
impulses  develop  early  and  to  an  abnormal  degree,  often 
leading  to  masturbation,  which  usually  becomes  deeply 
rooted  and  is  often  practised  in  addition  to  regular  sexual 
intercourse.  Occasionally  the  sexual  impulse  becomes  the 
central  point  about  which  the  entire  life  revolves,  producing 
the  picture  of  sexual  neurasthenia.    The  sexual  desire  may 


CONSTITUTIONAL  PSYCHOPATHIC   STATES  489 

be  accompanied  by  an  intense  feeling  of  discomfort,  even 
incapacitating  the  individual,  and  disappears  only  with 
gratification.  On  the  other  hand,  intense  feelings  of  anxiety 
may  accompany  the  sexual  act,  frustrating  its  accomplish- 
ment and  leading  to  mental  impotence.  Increased  sexual 
excitement  induces  reckless  masturbation,  resulting  in  a 
constant  overexcitation,  premature  ejaculation,  and  sper- 
matorrhoea, associated  with  hypochondriacal  fears.  Ulti- 
mately all  kinds  of  morbid  sensations  and  ideas  may  develop 
around  this  central  point. 

The  weakened  power  of  resistance  may  manifest  itself  in 
the  most  varied  ways.  Nervous  individuals  often  develop 
a  high  temperature  upon  slight  provocation,  easily  become 
delirious,  or  faint  during  excitement.  Furthermore,  there 
is  great  susceptibility  to  alcohol,  as  well  as  to  tea  and  coffee, 
rapid  collapse  under  stress,  inability  to  withstand  hunger  or 
thirst,  and  a  great  dependency  upon  weather  and  tempera- 
ture. There  is  also  a  tendency  to  pressure  in  the  head, 
headache,  false  sensations  of  all  kinds,  and  increased  irrita- 
bility of  the  heart.  The  taking  of  food  is  also  involved  in  the 
general  disturbance;  voracious  appetite  alternates  with 
loss  of  appetite,  nervous  dyspepsia  often  develops,  as  well 
as  sensations  of  pressure  or  fulness  in  the  stomach,  etc. 
Sleep  is  frequently  disturbed.  In  some  cases  there  is  an 
extraordinary  demand  for  sleep,  so  that  even  after  eight  or 
nine  hours  of  sleep  the  patients  can  hardly  be  aroused. 
Many  patients  feel  a  great  weariness  upon  awakening,  and 
their  sleep  is  disturbed  by  restless  dreams. 

Degeneracy  is  often  apparent  in  various  physical  defects; 
such  as,  a  lack  of  development  of  the  body  beyond  a  puerile 
stage,  either  a  very  youthful  or  a  senile  countenance,  local- 
ized or  general  cessation  of  development  of  the  brain  and 
skull,  abnormal  position  of  the  teeth,  malformation  of  the 


490  FORMS  OF  MENTAL  DISEASE 

ears,  palate,  sexual  organs,  and  hands.  Occasionally  there 
are  residuals  of  an  old  cerebral  disease. 

Course.  —  Since  nervousness  according  to  our  conception 
is  a  congenital  morbid  state,  one  cannot  speak  of  the  disease 
as  having  a  characteristic  course.  Usually  the  morbid  con- 
stitution first  shows  itself  in  childhood  by  great  restlessness, 
by  irritability,  sensitiveness  to  injuries,  minor  nervous  dis- 
turbances, convulsions,  enuresis,  night  horrors,  stuttering, 
etc.  Later,  difficulties  are  encountered  in  teaching  the 
children;  on  the  one  hand,  great  irritability,  passion,  and 
rebelliousness,  and  on  the  other,  susceptibility  to  seduction 
and  sexual  influences,  fickleness,  anxiety,  irresolution,  great 
sense  of  fatigue,  and  distractibility.  Occasionally  there 
develops  a  tendency  to  lying,  thieving,  and  truancy.  Many 
of  these  symptoms  may  improve  under  favorable  circum- 
stances. There  is  often  observed  an  increase  of  the  morbid 
symptoms  during  the  period  of  development,  in  spite  of  all 
possible  corrective  measures.  This  may  be  due  in  part  to 
the  unfavorable  influence  of  the  general  physical  and  mental 
evolution  at  this  period,  and  in  part  to  the  gradually  in- 
creasing demands  of  life.  Furthermore,  persistent  masturba- 
tion, alcoholic  excesses,  exhausting  diseases,  pregnancy  in 
women,  and,  under  some  conditions,  intense  emotional 
excitement  are  pernicious  influences  which  regularly  aid  in 
bringing  the  disease  to  its  full  development. 

Diagnosis.  —  Nervousness  is  often  mistaken  for  neu- 
rasthenia. In  neurasthenia  the  symptoms  of  fatigue  only 
are  present,  except  in  marked  conditions,  while  in  nervous- 
ness there  are  signs  of  degeneracy.  The  more  marked 
these  signs  are  in  a  given  disease  picture,  the  more  cautious 
one  should  be  in  considering  as  a  cause  for  the  condition 
an  alleged  nervous  exhaustion.  The  symptoms  of  simple 
nervous  exhaustion  rapidly  mend  under  the  influence  of  rest, 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  491 

but  the  symptoms  of  nervousness,  when  once  aroused,  run 
an  independent  and,  under  certain  conditions,  a  progressive 
course,  even  if  the  immediate  exciting  factors  have  been 
corrected.  In  addition  to  this,  nervousness  develops  at 
any  time  from  youth  up  without  any  appreciable  external 
cause  and  assumes  varied  forms,  while  nervous  exhaustion 
never  attacks  healthy  nervous  systems  without  some  power- 
ful injury. 

Treatment.  —  Prophylaxis  is  of  greatest  importance. 
Defective  persons  should  be  dissuaded  from  marrying  each 
other.  Of  the  particular  injurious  influences  to  be  com- 
bated, alcoholism  is  the  most  prominent.  During  child- 
hood patients  need  special  attention  paid  to  their  education 
and  training,  which  should  be  proportionately  divided  be- 
tween the  body  and  the  brain.  The  mental  development 
should  be  retarded  if  there  are  any  evidences  of  precocity. 
Particular  stress  should  be  laid  on  the  amount  of  sleep 
received,  and  the  patients  should  be  permitted  all  the  sleep 
they  desire.  At  the  time  of  the  awakening  of  the  sexual 
impulses,  the  children  must  be  carefully  watched  and  in- 
structed. Very  often  it  is  best  that  the  childhood  should  be 
passed  in  the  country,  in  order  to  give  the  body  as  much 
opportunity  as  possible  to  develop,  to  eliminate  confinement 
in  school,  and  to  avoid  the  pernicious  influences  of  bad 
associations  in  cities.  If  the  disorder  is  very  pronounced, 
manual  training  under  the  supervision  of  a  physician  is 
desirable.  Psychopathic  children,  on  account  of  their  faulty 
constitution,  do  not  tolerate  routine  training  well.  The 
training  should  be  adapted  to  personal  peculiarities.  In 
the  choice  of  an  occupation  one  must  take  into  consideration 
their  imperfections.  Uncongenial  and  annoying  employment 
makes  the  symptoms  worse,  while  simple,  regular,  and 
uniform   work   often    does   much   good.     Patients   should 


492  FORMS  OF  MENTAL  DISEASE 

avoid  all  excesses.  Alcohol  in  any  form  must  be  forbidden. 
Furthermore,  morphin  and  hypnotics  can  be  prescribed  only 
with  the  greatest  care. 

The  individual  symptoms  themselves  are  best  combated 
by  means  of  an  intelligent  training  under  medical  super- 
vision, regulation  of  the  entire  life,  with  due  regard  to  a  pro- 
portionate amount  of  work  and  recreation,  sufficient  sleep 
and  nourishment.  Long-drawn-out  "  cures  "  are  usually 
unsatisfactory,  especially  in  institutions,  as  the  complaints 
and  hypochondriacal  fears  tend  to  increase  under  such  con- 
ditions, and  should  be  resorted  to  only  for  very  definite 
reasons.  On  the  other  hand,  the  necessity  of  meeting  some 
regular  obligations  serves  as  an  important  remedy.  If 
relaxation  is  necessary,  it  is  usually  best  accomplished  by  a 
short  journey  or  a  sojourn  at  the  sea  or  in  the  mountains. 
These  patients,  in  general,  demand  frequent  but  short  pe- 
riods of  relaxation.  Where  there  is  despondency,  diversion 
is  best  obtained  by  means  of  social  intercourse,  distractions, 
artistic  efforts,  and  amusements. 

B.   Constitutional  Despondency 

Constitutional  despondency  is  characterized  by  a  'per- 
sistent feeling  of  sadness  which  pervades  all  of  life's  expe- 
riences. 

Intellect  shows  no  striking  disturbances.  Some  patients 
are  well  endowed,  while  others  from  youth  are  somewhat 
backward  in  mental  development.  The  susceptibility  to  fa- 
tigue is  greatly  increased ;  while  patients  are  capable  of  tak- 
ing up  a  piece  of  work  with  intelligence  and  skill,  they  tire 
quickly,  demand  frequent  rests,  and  are  wholly  unfit  for 
steady  application  to  mental  or  physical  work,  because  of 
resulting  headache,  insomnia,  or  general  malaise.     Under 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  493 

stress  of  circumstances  they  are  often  able  to  temporarily 
overcome  these  hindrances.  Distractibility  of  the  attention 
is  greatly  increased,  so  that  even  the  most  trifling  affairs 
in  the  surroundings  may  greatly  interfere  with  system- 
atic work.  Hence  their  work  is  uncertain,  and  sometimes 
has  to  be  done  over  several  times.  There  is  a  tendency 
to  display  hypochondriacal  complaints.  Consciousness  re- 
mains unclouded,  and  thought  is  coherent.  Patients 
often  appreciate  their  unfortunate  condition. 

In  emotional  attitude  they  are  oppressed  and  sorrowful. 
They  may  have  always  been  especially  susceptible  to  the 
cares,  sorrows,  and  misfortunes  of  life.  Present  pleasure  is 
always  clouded  by  past  sorrow  or  troubled  fears  for  the 
future.  Many  patients  to  all  external  appearances  seem 
normal  and  only  disclose  their  sadness  to  their  families  or 
the  physician.  Under  the  influence  of  some  excitement 
they  may  temporarily  become  happy  and  cheerful,  but  soon 
relapse  again  into  their  misery.  Any  undertaking  dismays 
them,  and  they  take  little  or  no  pleasure  in  any  occupation. 
They  lack  self-confidence,  are  easily  discouraged,  feel  that 
they  are  of  little  use  in  the  world,  are  nervous,  sick,  and  fear 
the  outbreak  of  some  awful  disease,  especially  insanity. 
Some  are  always  troubled  with  the  feeling  that  they  have 
done  something  wrong,  or  that  some  ill  will  befall  them. 
They  are  especially  apt  to  worry  about  their  sexual  life. 
The  sexual  impulses  are  usually  awakened  early  and  lead  to 
excesses,  especially  masturbation,  the  consequences  of  which 
the  patients  always  paint  in  the  darkest  colors.  Sometimes 
the  patients  are  sentimental. 

Conduct  is  greatly  influenced.  If  anxiety  predominates, 
patients  shrink  from  every  obligation,  dread  the  most  remote 
possibilities,  and  avoid  everything  to  which  they  are  unac- 
customed.    Many  patients  are  deliberate,  find  it  difficult 


494  FORMS  OF  MENTAL   DISEASE 

to  arrive  at  a  decision,  and  tend  to  exhibit  great  precision 
and  punctuality  in  little  things.  They  use  an  endless  amount 
of  time  without  accomplishing  anything.  They  stick  so 
tenaciously  to  every  task  that  they  are  gradually  reduced 
to  a  smaller  and  smaller  sphere  of  activity.  They  excuse 
themselves  for  not  going  out  into  society  because  they 
have  not  time,  and  they  cannot  travel  because  it  is  too  diffi- 
cult to  get  ready.  Ultimately  their  whole  activity  may  be 
confined  to  keeping  the  house  clean  and  preparing  meals  on 
time.  Some  patients  are  constantly  thinking  of  death  and 
are  always  making  preparations  to  die.  Though  they  may 
not  seem  in  earnest  about  it,  yet  it  not  infrequently  happens 
that  they  make  attempts  at  suicide.  Very  often  all  sorts 
of  nervous  complaints  interfere  with  their  ability  to  work, 
such  as  pressure  and  pain  in  the  head  and  peculiar  sensa- 
tions in  all  parts  of  the  body.  Occasionally  some  peculiar 
motor  symptoms  are  observed,  as  grimacing,  choreiform 
movements,  clucking  with  the  tongue,  snuffling,  and  twitch- 
ing of  muscles.  These  "  tics  "  accompany  all  the  different 
forms  of  degeneracy.     Sleep  is  usually  much  disturbed. 

Course.  —  The  course  of  the  disease  is  prolonged,  with 
irregular  remissions;  but  within  certain  limits  it  runs  a  very 
uniform  course,  lasting  for  years.  The  condition  regularly 
becomes  worse  after  emotional  shocks  and  physical  disease 
and  even  without  any  apparent  cause.  Gradually  the 
patients  may  become  better,  but  it  rarely  happens  that  they 
are  entirely  free  from  symptoms.  At  first  remissions  may 
occur,  but  later  there  is  a  tendency  for  the  symptoms  to 
persist,  until  finally  there  is  a  continuous  morbid  condition 
with  little  variation.  Even  during  the  remissions,  patients 
always  display  some  evidence  of  mental  peculiarities:  they 
are  quiet,  dull,  shy,  or  unfriendly. 

Treatment.  —  The  patients  can  be  made  very  comfortable 


CONSTITUTIONAL   PSYCHOPATHIC   STATES  495 

by  a  well-regulated  life  in  a  favorable  environment,  but 
family  strife  and  increased  responsibilities  always  diminish 
chances  of  recovery.  On  the  other  hand,  absolute  freedom 
tends  to  make  the  patients  worse.  Suitable  employment  is 
necessary,  which  must  be  so  adjusted  as  to  gradually  increase 
the  responsibility  and  the  exercise  of  strength.  While  the 
special  therapeutic  agencies,  as  massage,  hydrotherapy, 
electricity,  etc.,  are  of  importance,  their  chief  value  lies  in  the 
psychical  influence  which  can  be  exerted  through  them  in 
creating  new  energy  for  work  and  in  establishing  self-con- 
fidence. Hypnotic  suggestion  is  often  helpful  in  cases  with 
insomnia  and  pain. 

Q.     Constitutional  Excitement 

Constitutional  excitement  constitutes  a  small  group  of 
cases  characterized  by  permanent  moderate  psychomotor 
excitement. 

The  intellect  of  these  patients  is  fairly  good,  but  they 
are  hindered  in  acquiring  full  and  complete  knowledge, 
because  they  are  not  persistent  at  their  studies  and  are 
extremely  distractible.  Perception  is  usually  unimpaired, 
knowledge  of  life  and  the  world  is  superficial,  mental  elabo- 
ration of  experiences  is  hazy  and  scanty,  and  memory  of  early 
experiences  is  fleeting,  one-sided,  and  often  colored  and 
falsified  with  many  additions.  Thought  is  nighty  and  aim- 
less, and  judgment  is  hasty  and  superficial. 

In  emotional  attitude  the  patients  are  happy  and  thought- 
less. They  possess  a  marked  feeling  of  egotism  and  are  boast- 
ful of  their  own  capabilities  and  accomplishments.  They 
do  not  appreciate  their  imperfections.  Toward  others  they 
are  apt  to  be  lofty,  irritable,  dogmatic,  and  unsympathetic. 
They  usually  deride,  torment,  and  abuse  those  who  do  not 


496  FORMS  OF  MENTAL  DISEASE 

agree  with  them,  but  on  the  other  hand,  they  do  not  become 
mortified  when  reproached  and  insulted.  They  devote  much 
time  to  amusements  and  diversions  of  all  kinds  and  are  given 
to  making  fun  of  themselves  and  others  and  playing  tricks. 
They  readily  adapt  themselves  to  new  conditions  and  are 
always  longing  for  a  change.  Occasionally  transitory,  anx- 
ious, or  despondent  emotional  conditions  develop. 

In  actions  and  manner  the  patients  are  restless  and  un- 
stable. They  are  easily  approachable,  often  loquacious, 
but  wholly  untrustworthy  and  vacillating  in  their  judgment. 
Consequently  their  lives  are  one  series  of  thoughtless, 
venturesome,  and  often  foolish  acts.  Even  in  school  they  are 
rebellious  and  disorderly.  They  react  badly  under  military 
discipline,  neglect  the  rules  of  cleanliness  and  order,  misuse 
furloughs,  neglect  their  duties,  and  frequently  need  to  be 
punished.  Sexual  impulses  often  develop  early  and  lead  to  ex- 
cesses. They  frequently  become  addicted  to  the  use  of  alco- 
hol. They  are  constantly  moving  and  changing  employment 
without  sufficient  reason,  always  beginning  something  new 
and  devising  great  schemes  which  are  soon  forgotten. 
They  often  make  propositions  which  they  cannot  live  up  to, 
assume  lofty  titles,  and  secure  recognition  by  boasting. 
The  lack  of  plan  in  their  undertakings  is  most  characteristic 
and  clearly  shows  how  little  their  pressure  of  activity  is 
held  in  check  by  careful  reasoning.  They  soon  exhaust 
their  resources,  and  then  they  begin  to  borrow,  to  cheat,  and 
to  swindle.  In  trying  to  maintain  their  credit  they  always 
refer  to  some  great  "deal"  which  they  are  about  to  put 
through,  a  position  which  awaits  them,  their  intimacy  with 
prominent  individuals,  betrothals  to  heiresses,  etc.  When 
thwarted  they  maintain  that  they  are  in  the  right,  that  they 
had  no  idea  of  fraud,  and  that  they  will  shortly  be  in  a 
position  to  meet  all  of  their  obligations.     Following  punish- 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  497 

ment,  they  again  return  to  their  old  tricks,  until  finally 
the  morbid  character  of  their  conduct  is  recognized. 

Diagnosis.  —  The  similarity  of  constitutional  excitement 
to  hypomania  is  very  striking.  The  differentiation  depends 
upon  the  fact  that  in  constitutional  excitement  the  excite- 
ment is  less  pronounced,  does  not  recur  in  definite  attacks, 
but  is  a  fixed  personal  peculiarity.  Nevertheless  some  cases 
of  constitutional  excitement  develop  transitory  exacer- 
bations and  even  delirious  states,  while  others  show  periodi- 
cal vacillations  together  with  irritability  and  rebelliousness, 
and,  finally,  occasional  anxious  states  with  indefinite  delu- 
sions of  persecution.  These  cases  are  only  another  indication 
that  we  really  have  to  do  with  a  permanent  disorder  of  the 
mental  equilibrium  which  constitutes  the  first  step  toward 
true  manic  excitement.  These  cases  also  remind  one  of  those 
cases  of  manic-depressive  insanity,  in  the  lucid  intervals  of 
which  moderate  excitement  of  the  same  character  occurs. 
Some  refer  to  both  conditions  as  a  chronic  or  constitutional 
mania. 

The  mildest  forms  of  constitutional  excitement  approach 
very  closely  to  certain  defective  constitutions  which  are 
ordinarily  regarded  as  belonging  within  the  realm  of  normal 
man.  These  are  usually  encountered  in  families  some  of 
whose  members  have  suffered  from  forms  of  manic-depres- 
sive insanity.  They  comprise  certain  brilliant  but  never- 
theless one-sided  personalities  which  charm  one  by  their 
versatility,  their  enthusiasm,  their  artistic  abilities,  and 
happy,  sunny  dispositions,  but  who  at  the  same  time  astonish 
one  by  their  restlessness,  volubility,  lack  of  steadiness  and 
persistency  in  employment,  and  their  tendency  to  evolve 
numerous  schemes.  Occasionally  they  exhibit  periods  of 
unreasonable  despondency,  which  sometimes  follow  over- 
work and  disappointments.    The  frequent  history  of  de- 

2k 


498  FORMS  OF  MENTAL  DISEASE 

spondency  ending  in  suicides  occurring  in  the  parents, 
brothers,  sisters,  and  their  children,  or  of  genuine  manic- 
depressive  insanity,  leads  to  a  strong  presumption  that 
sanguine  temperaments  of  this  sort  are  nothing  more  than 
initial  psychopathic  stages  of  manic  excitement. 

Treatment.  —  The  treatment  is  difficult  because  the 
patients  lack  insight  into  their  condition  and,  therefore, 
will  not  submit  to  medical  advice.  In  many  cases  it  is 
necessary  to  occasionally  restrict  the  freedom  of  the  patients, 
because  otherwise  they  get  into  serious  difficulties.  By 
means  of  firm  and  friendly  guidance  and  especially  by  suffi- 
cient protection  against  sexual  and  alcoholic  excesses  these 
patients  can  sometimes  be  made  to  follow  some  useful 
employment,  but  in  spite  of  all  advice  and  regulation  they 
always  remain  fickle  and  unreliable  and  a  source  of  constant 
care  and  anxiety  to  their  friends. 

D.     Compulsive  Insanity 

In  this  psychopathic  state  compulsive  ideas  and  compulsive 
fears  are  the  predominant  symptoms. 

The  intellect  is  not  only  undisturbed,  but  may  be  unusu- 
ally good.  Patients  exhibit  throughout  a  pronounced  feel- 
ing of  mental  illness  and  frequently  a  clear  insight  into 
the  morbidity  of  the  individual  symptoms.  Many  present 
symptoms  of  constitutional  despondency  before  the  com- 
pulsive ideas  and  fears  appear.  Moreover,  the  initial  symp- 
toms usually  develop  during  conditions  of  despondency. 

The  compulsive  symptoms  may  be  grouped  under  three 
heads :  the  tormenting  ideas  (manies  mentales),  the  phobias, 
and  the  impulsions. 

Tormenting  Ideas.  The  feeling  of  anxious  uneasiness 
which  accompanies  all  of  these  symptoms  produces  a  se- 
ries  of    psychogenic   disturbances.     It   is   not   improbable 


CONSTITUTIONAL  PSYCHOPATHIC   STATES  499 

that  the  sensation  of  strangeness  referred  to  in  nervousness 
is  nothing  more  than  a  peculiar  expression  of  a  concealed  anx- 
iety, which  impairs  the  patients'  sensations  and  influences 
the  perception  of  the  outer  world.  Consequently  the  feel- 
ing frequently  arises  in  the  patients  that  they  cannot  com- 
prehend anything  more,  cannot  follow  conversation,  or  can- 
not get  the  sense  of  that  which  is  read.  Thus  there  develops 
an  endless  repetition  of  the  same  tormenting  thoughts  which 
disturb  the  patients  all  the  more  if  they  attempt  to  dispel 
them.  Associated  with  these  feelings  there  develop  peculiar 
physical  sensations  all  over  the  body;  such  as,  weariness, 
palpitation  of  the  heart,  blushing,  blanching,  nausea,  and 
sometimes  even  vomiting.  Furthermore,  the  anxiety  leads 
to  a  mixture  of  voluntary  and  involuntary  impulses,  which 
are  thus  altered  in  various  ways.  Finally  the  patients  evolve 
peculiar  methods  of  self-relief. 

The  simplest  form  of  compulsive  insanity  is  represented 
by  the  simple  compulsive  ideas  which  force  themselves  upon 
the  patients  against  their  will,  and  in  this  way  influence  the 
freedom  of  thought.  Sometimes  the  compulsive  idea  is 
very  simple  or  at  least  not  irritating.  It  is  only  the  frequent 
repetition  of  the  idea  that  causes  annoyance.  Sometimes 
the  idea  is  accompanied  by  an  hallucinatory  picture  of  great 
vividness.  Odors  and  melodies  may  similarly  haunt  patients. 
Such  ideas  are  especially  annoying  when  they  are  disgusting 
or  create  horror.  Many  patients  complain  because  they  are 
compelled  to  contemplate  the  sexual  organs  of  those  about 
them.  Others  when  at  stool  have  to  dwell  upon  all  sorts  of 
disgusting  scenes. 

In  another  group  of  cases  there  is  a  compulsion  to  ponder 
over  certain  definite  things;  for  example,  the  names  of  per- 
sons (onomatomania),1  and  particularly  difficult  names. 
1  Magnan,  Psychiatrische  Vorlesungen,  1893. 


500  FORMS  OF  MENTAL  DISEASE 

Unable  to  recollect  a  name  casually  heard  or  seen,  the 
patients  immediately  strain  every  nerve  to  recall  it,  think 
about  it  all  day  long,  lie  awake  nights  trying  to  recall  it, 
and  the  tension  cannot  be  relieved  until  they  succeed. 
Some  patients  feel  compelled  to  inquire  the  names  of  people 
whom  they  meet  on  the  street;  others  feel  that  they  must 
form  a  definite  picture  of  the  face,  form,  or  color  of  the  hair 
of  strangers.  Other  patients  dwell  on  figures  (arithmo- 
mania),  and  are  compelled  to  busy  themselves  with  the 
number  of  the  house,  the  street,  the  number  of  guests  about 
the  table,  the  number  of  forks,  knives,  and  glasses,  the  num- 
ber of  designs  in  the  carpet  or  wall  paper. 

Compulsive  ideas  sometimes  take  the  form  of  questions; 
as,  "  Who  is  God?"  "How  was  the  universe  created?" 
etc.  Sometimes  these  questions  refer  to  objects  in  the 
surroundings,  when  such  questions  arise  as,  "  Why  does 
that  chair  stand  thus  and  not  so?  "  "  Why  does  it  have 
four  legs  and  no  more  or  less  ?  "  "  Why  is  that  house  painted 
green  and  not  brown?  "  This  has  been  been  called  Griibel- 
sucht  —  a  passion  for  pondering  over  things. 

Some  patients  are  in  doubt  as  to  the  accuracy  of  their 
memory;  still  others  have  the  feeling  that  they  may  not 
recognize  their  acquaintances  when  they  meet  them  again, 
or  will  not  remember  what  they  last  said  to  them.  Some- 
times these  feelings  of  uncertainty  seem  like  ideas  of  self- 
accusation.  Patients  feel  that  they  have  neglected  some- 
thing or  have  not  done  something  right.  When  urinating 
or  defecating,  the  patients  may  have  the  feeling  that  the  dis- 
charge is  incomplete,  and  therefore  they  must  make  fur- 
ther efforts.  After  every  conversation  the  idea  arises  that 
they  may  not  have  made  themselves  clearly  understood. 
After  leaving  a  friend,  they  sit  down  and  write  a  letter  in 
order  to  be  sure  that  they  are  understood,  but  the  letter  is 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  501 

barely  off  before  they  are  in  doubt  as  to  whether  they  made 
themselves  clear  in  it.  These  patients  weigh  every  word 
before  they  express  themselves,  trying  to  avoid  false  inter- 
pretations. Some  patients  always  have  the  idea  that  they 
have  taken  some  other  person's  hat,  umbrella,  or  overcoat. 
In  counting  money  they  carefully  scrutinize  every  coin 
for  fear  that  they  might  have  made  a  mistake,  or  that  they 
had  not  paid  out  enough,  and  hence  would  be  accused  of 
fraud.  Many  patients  accuse  themselves  of  not  having 
confessed  everything  at  the  confessional  or  of  not  being 
"  contrite  of  heart." 

Very  often  the  patients  have  the  fear  of  destroying  or 
misplacing  something  of  value.  In  many  cases  their  fears 
are  quite  silly;  they  feel  that  they  are  guilty  of  crime,  of 
homicide,  have  committed  a  theft,  or  have  poisoned  a  rela- 
tive. In  the  lighter  forms  these  doubts  exist  only  in  one 
field  of  activity;  in  the  severer  forms  they  influence  all  the 
actions  of  the  patients.  "  Perhaps  it  would  have  been  bet- 
ter if  I  had  not  drunk  that  glass  of  water,"  or  "  I  have  harmed 
myself  by  taking  that  piece  of  cake."  "  Had  I  not  gone 
out  of  doors,  it  would  have  been  better;  that  accident  would 
not  have  happened  or  that  fire  would  not  have  broken  out." 
It  is  actually  impossible  for  these  patients  to  remain  at  rest 
because  of  the  uncertainty  as  to  whether  they  have  closed  a 
door  or  have  sealed  a  letter  that  they  have  mailed.  Con- 
sequently they  manifest  an  ever  increasing  painstaking  in 
all  the  little  details  of  daily  life.  They  are  always  turning 
back  to  see  if  they  have  locked  the  door,  or  tearing  open 
letters  to  see  if  they  have  enclosed  the  right  one.  It  is  often 
characteristic  of  these  patients  to  make  use  of  some  par- 
ticular phrase  or  movement  which  they  have  discovered, 
such  as  "  High  Jinks,"  or  to  cough,  upon  which  all  doubt 
is  dispelled.  This  whole  group  of  cases  has  been  desig- 
nated by  Legrand  du  Saulle  as  "folie  du  doute." 


502  FORMS  OF  MENTAL  DISEASE 

There  is  also  a  condition  called  erythrophobia,  in  which 
patients  fear  blushing.  When  any  one  enters  the  room  or 
their  name  is  spoken,  they  immediately  blush,  which  causes 
great  discomfort  for  fear  that  they  may  be  thought  guilty 
of  some  misdeed.  It  may  even  create  so  much  annoyance 
that  they  are  compelled  to  give  up  business.  There  is  also 
the  fear  of  wearing  new  clothing  because  of  the  newness  and 
accompanying  physical  discomforts. 

The  strongest  feelings  are  connected  with  the  welfare  of 
the  body.  Many  patients  perceive  all  kinds  of  sensations 
in  their  bodies  which  cause  them  anxiety.  When  dropping 
off  to  sleep,  the  body  seems  to  increase  to  an  enormous  size. 
Some  patients  have  the  uncomfortable  feeling  that  the  urine 
is  trickling.  They  fear  that  they  are  going  to  lose  their 
minds  or  become  paralyzed.  Others  have  the  idea  they  will 
suffer  from  syphilis.  Some  fear  a  sunstroke,  and  in  conse- 
quence are  taking  all  possible  precautions ;  still  others  have 
the  foolish  fear  of  snakes,  of  cats,  or  that  a  beetle  will  crawl 
into  their  ears.  Some  avoid  going  into  the  street  for  fear 
that  a  stone  or  a  man  may  fall  upon  them  from  a  building. 
The  sexual  relations  also  offer  a  fruitful  field  for  compul- 
sive fears.     Such  fears  often  frustrate  the  sexual  act. 

Phobias.  In  the  "  phobias "  fear  arises  in  connection 
with  certain  definite  conditions.  It  is  impossible  to  draw 
a  sharp  distinction  between  the  states  described  above  and 
those  of  phobia,  as  they  are  often  intimately  associated. 
But  the  phobias  are  always  characterized  by  the  sudden 
appearance  of  pronounced  anxiety  in  connection  with  the 
general  idea  of  fear.  When  subjected  to  them,  patients 
may  suffer  from  palpitation  of  the  heart,  become  pale, 
tremble,  have  a  cold  sweat,  nausea,  faintness,  polyuria, 
weakness  of  the  legs,  and  finally  may  even  lose  control  of 
themselves  and  collapse.    The  conditions  in  connection  with 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  503 

which  such  attacks  of  fear  arise  are  varied,  yet  there  are 
some  forms  which  recur  with  notable  regularity.  Sometimes 
the  same  patient  may  suffer  from  a  whole  series  of  phobias. 
The  best  known  of  these  is  agoraphobia,  in  which  there  is 
great  fear  of  public  places.  Patients  are  unable  to  walk 
down  a  long,  broad  street  or  in  a  place  where  they  are  alone. 
When  they  attempt  this,  they  are  so  overcome  that  they  can- 
not proceed.  When  the  condition  is  extreme,  they  are 
afraid  to  go  out  on  the  street  at  all,  some  even  remaining  in 
bed.  Closely  related  to  this  is  the  fear  of  height  which  pre- 
vents patients  from  standing  near  a  railing,  on  the  brink 
of  a  precipice,  going  over  bridges,  or  of  being  in  a  theatre. 
Among  other  morbid  fears  might  be  mentioned  that  of 
being  alone  in  the  dark,  riding  on  trains,  and  going  through 
tunnels.  These  patients  find  no  pleasure  in  travelling,  do 
not  enjoy  going  to  church,  and  always  sit  near  the  door, 
ready  to  fly  at  the  first  sign  of  danger.  Various  phobias 
may  develop  in  connection  with  the  occupation  of  the  pa- 
tients ;  for  instance,  barbers  sometimes  suffer  these  attacks 
whenever  they  see  a  razor,  or  telegraphers  when  they 
catch  sight  of  their  instruments,  etc.,  which  finally  neces- 
sitates giving  up  the  occupation. 

Among  women,  especially,  there  occurs  the  fear  of  dirt 
(mysophobia),  contagion,  or  infection.  The  countless  bac- 
teria always  present  in  the  air  are  one  of  the  chief  sources 
of  annoyance.  The  patients  are  everywhere  complaining 
of  the  bad  air  and  throwing  up  windows;  they  are  afraid 
of  handling  brass  or  copper,  or  are  always  taking  things  up 
by  nails  or  pieces  of  glass.  They  notice  in  their  food  a 
shining  bit  which  may  possibly  be  a  pin.  Books,  especially, 
are  avoided  as  a  possible  source  of  contagion.  Occasion- 
ally a  patient  has  the  fear  of  destroying  something  of  value. 
One  lady  was  always  in  fear  of  throwing  some  important 


504  FORMS  OF  MENTAL  DISEASE 

letter  into  the  fire  or  destroying  it,  and  for  this  reason  care- 
fully avoided  touching  any  paper  and  finally  even  printed 
books.  Patients  are  constantly  washing  themselves,  and 
are  fearful  of  disease  from  touching  money,  books,  or  papers. 
In  taking  food  they  have  to  wipe  the  dishes  frequently  and 
inspect  carefully  eveiy  morsel. 

As  the  result  of  fear  of  misplacing  something  or  of  soiling 
themselves  there  develops  the  fear  of  contact,  delire  du 
toucher.  Patients  throw  away  all  the  needles  in  the  house, 
and  they  give  up  sewing  for  fear  that  they  may  injure  them- 
selves. They  no  longer  wash  the  windows,  because  the  glass 
might  break  and  cut  them.  They  refuse  to  shake  hands, 
but  wear  gloves  and  open  windows  with  their  elbows.  They 
begin  the  habit  of  washing  not  only  their  hands,  but  also 
all  of  their  clothing.  Some  patients  spend  the  entire  day 
in  dressing,  undressing,  and  washing. 

A  common  characteristic  of  almost  all  phobias  are  the 
crises.  As  soon  as  one  threatens  to  do  that  feared  by  the 
patients  or  to  hinder  them  from  carrying  out  their  usual 
means  of  protection,  they  develop  an  anxious  condition  with 
excitement.  It  is  quite  astonishing  to  see  how  patients, 
until  now  hoping  for  relief  of  the  disease,  suddenly  turn  about 
and  oppose  any  real  attempt  at  combating  it. 

Impulsions.  —  In  this  last  series  of  cases  the  compulsive 
fears  apparently  take  the  form  of  impulses.  In  reality, 
however,  we  still  have  to  do  only  with  fears  which  are  di- 
rected against  the  dangers  that  the  patients  suppose  are 
threatening  them.  Such  questions  as  the  following  press 
themselves  upon  the  patients :  "  What  would  happen  if  you 
should  undertake  to  do  this  or  that,  if  you  should  kill  some 
one  with  that  knife,  or  set  that  building  on  fire,  or  shout 
aloud  in  church  ?  "  Whenever  they  see  sores  or  ulcers  they 
feel  impelled  to  touch  them,  and  at  the  sight  of  filth  must 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  505 

wallow  in  it.  It  seems  to  them  they  must  smear  every- 
thing with  urine.  Religious  anxieties  create  the  idea  of 
fouling  the  communion  bread,  or  of  bringing  it  in  contact 
with  the  genitals.  Other  patients  think  that  they  must 
bore  nails  into  the  heads  of  their  children,  cut  off  their  heads, 
commit  sexual  assaults  upon  them,  steal  the  silver  from 
the  table,  or  rip  open  their  own  abdomen  or  that  of  others. 
Usually  these  thoughts  arise  in  connection  with  beloved 
ones.  Sometimes  illusions  are  associated  with  these  ideas, 
when  the  patients  see  a  bloody  knife  suspended  before 
their  eyes,  are  followed  by  a  picture,  feel  as  if  their  arms 
and  hands  are  extending  out  to  grasp  a  pile  of  filth,  etc. 
Thus,  there  arises  a  fear  of  all  objects,  which  can  call  up 
impulses  of  these  kinds.  The  patients  no  longer  venture 
to  attend  communion  and  show  the  greatest  anxiety  when 
coming  in  contact  with  dangerous  weapons.  Many  patients 
permit  themselves  to  be  locked  up  or  to  be  bound,  in  order 
that  they  may  withstand  these  impulses.  In  reality,  how- 
ever, these  patients  never  perform  the  dreaded  acts ;  at 
most  it  only  happens  that  they  are  unable  to  withstand 
the  temptation  to  flee  from  some  religious  ceremony  or 
during  prayer  to  substitute  some  blasphemous  or  obscene 
expression. 

The  consciousness  of  all  these  patients  is  entirely  clear. 
They  have  an  insight  into  their  condition,  and  the  desire, 
but  not  the  strength,  to  free  themselves  from  it.  They  know 
well  enough  that  no  real  harm  threatens  them,  but  that  they 
are  overwhelmed  only  by  the  "  fear  of  the  fear."  Their 
emotional  attitude  shows  anxiety  which  often  is  in  marked 
contrast  to  their  courage  in  real  danger.  They  are  usually 
of  a  weak,  dependent  nature.  In  their  behavior  and  actions 
they  frequently  show  nothing  abnormal,  and  control  them- 
selves perfectly  before  strangers. 


506  FORMS  OF  MENTAL  DISEASE 

Course.  —  The  course  of  the  disease  varies  much.  Com- 
plete disappearance  of  the  symptoms  seldom  occurs,  and 
then  only  for  a  short  time,  but  rapid  improvement  is  often 
noticed,  usually  during  the  period  of  development. 

Prognosis.  —  The  prognosis  in  general  is  unfavorable. 
Occasionally,  especially  in  cases  of  simple  compulsive  ideas, 
agoraphobia,  and  the  allied  symptoms,  the  disturbance 
may  disappear  for  longer  or  shorter  periods,  but  there  is 
great  fear  of  relapses.  There  are  many  cases  in  which  strik- 
ing symptoms  appear  temporarily  only  under  the  influence  of 
specially  unfavorable  conditions.  In  the  folie  du  doute  and 
the  fear  of  contact  there  is  little  chance  for  improvement. 
On  the  other  hand,  compulsive  insanity  never  develops  into 
other  psychoses,  as  the  patients  often  fear. 

Treatment.  —  The  treatment  is  chiefly  directed  to  com- 
bating the  condition  of  degeneracy.  In  youth  careful 
attention  to  the  demands  of  physical  development  is  neces- 
sary. Threatening  peculiarities  should  be  warded  off  by 
careful  training,  and  all  deleterious  influences  removed 
which  tend  to  weaken  the  physical  and  mental  powers  of 
resistance.  The  symptoms  of  the  disease  can  be  combated 
by  persistent  and  patient  training  with  a  view  to  strength- 
ening and  encouraging  the  patients  to  struggle  step  by  step 
against  the  morbid  compulsion.  The  significance  of  their 
condition  should  always  be  made  clear  to  the  patients,  and 
they  must  be  impressed  with  the  fact  that  they  will  over- 
come it  more  by  abstraction  and  diversion  than  by  exercise 
of  will  power.  Occasional  interviews  with  the  physician 
aid  in  quieting  the  patient  and  giving  him  additional  cour- 
age. Hypnotic  suggestion  may  be  of  value  during  crises 
in  supporting  the  patients,  but  its  influence  is  transitory. 


CONSTITUTIONAL  PSYCHOPATHIC   STATES  507 

E.    Impulsive  Insanity 

Impulsive  insanity  is  characterized  by  the  development  of 
morbid  tendencies  and  impulses  which  either  dominate  over 
volition  continually  or  in  recurring  paroxysms. 

These  acts,  which  appear  without  motive,  are  performed 
because  of  an  irresistible  impulse.  The  impulses  do  not 
arise  as  the  result  of  a  conscious  plan,  but  appear  suddenly, 
are  quickly  executed,  and  often  quite  indefinite,  thereby 
causing  the  actions  to  appear  unpremeditated,  purposeless, 
and  even  absurd.  In  case  the  act  is  serious  or  dangerous, 
its  accomplishment  may  be  preceded  by  a  conscious  struggle. 
But  yet  the  worst  acts  are  often  performed  without  delay, 
and  as  a  matter  of  course.  Neither  the  regret  that  follows 
the  act  nor  the  fear  for  the  results  suffices  to  suppress  the 
recurrence  of  similar  impulses. 

Those  so-called  normal  individuals  who  suffer  from  tri- 
fling and  insignificant  impulses,  which  appear  only  under 
certain  circumstances,  disappear  rapidly,  and  lead  to  very 
simple  acts,  represent  a  sort  of  transition  stage  between  nor- 
mal health  and  impulsive  insanity.  Maudsley  tells  of  a  man 
who  for  weeks  was  annoyed  by  an  impulse  to  overturn  two 
stones  which  lay  upon  a  wall,  finally  forcing  him  to  sneak 
out  at  night  in  order  to  perform  the  absurd  act.  Such  im- 
pulses become  of  more  consequence  to  the  patient  when  they 
are  constantly  involving  the  environment  and  interfering 
with  comfort  and  occupation.  The  impulses  that  develop  in 
certain  definite  directions  are  of  far  more  importance. 
These  include  the  impulse  to  tramp,  to  set  fire,  to  steal,  and  to 
destroy  or  kill. 

In  the  impulse  to  ramble  the  patients  are  suddenly  seized 
with  an  intense  desire  to  roam  about,  sometimes  in  connec- 
tion with  some  sort  of  an  adventurous  purpose.     So  they 


508  FORMS  OF  MENTAL  DISEASE 

wander  about  here  and  there  until  their  means  are  exhausted. 
They  have  a  clear  memory  of  their  experiences,  and  they  do 
not  see  anything  peculiar  in  their  conduct.  Occasionally 
during  these  periods  they  commit  all  sorts  of  frauds,  assume 
false  names,  and  are  boastful. 

The  impulse  to  set  fire  (pyromania)  is  exhibited  espe- 
cially by  young  females,  most  often  during  puberty.  Some- 
times the  morbid  pleasure  of  seeing  things  burn  and  at 
hearing  the  crackle  dates  from  early  childhood.  Another 
common  form  of  impulse  is  the  tendency  to  skilful  but  fool- 
ish stealing  {kleptomania),  encountered  almost  exclusively 
among  women,  and  especially  during  menstruation  and 
pregnancy.  The  stolen  articles  are  frequently  almost  or 
quite  worthless  for  the  patients.  In  some  cases  there  is  a 
desire  for  some  one  definite  thing  which  is  accumulated  in 
great  quantities.  Sexual  impulses  may  accompany  this 
condition.  Further  expressions  of  degeneracy  of  normal 
impulses  are  seen  in  silly  fondness  for  animals,  irresistible 
tendency  to  play,  marked  increase  of  sexual  impulses,  and 
many  similar  digressions. 

Morbid  impulses  to  destroy  and  kill  are  other  instances. 
There  is  a  special  group  of  young  women  who  show  a  morbid 
impulse  to  beat  little  children  intrusted  to  their  care.  Here 
there  exists  a  close  relationship  to  those  sexual  impulses 
which  have  been  called  sadism,  masochism,  and  fetichism. 
The  men  who  prod  women,  who  snip  hair,  slash  ladies' 
dresses,  steal  women's  shoes  or  linen,  and  many  exhibitionists 
belong  to  this  class. 

The  mental  endowment  of  these  patients  usually  shows  no 
marked  defect,  but  in  some  severe  cases  there  is  a  more  or 
less  high  grade  of  mental  weakness.  In  the  emotional  field 
the  defect  is  more  evident ;  the  patients  are  apt  to  be  child- 
ish, unstable,  shy,  seclusive,  or  vulgar. 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  509 

Course.  —  The  symptoms  of  the  disease  appear  only  dur- 
ing certain  periods  of  life,  and  particularly  during  the 
period  of  development,  at  which  time  there  is  a  condition 
of  lessened  resistance  in  both  the  physical  and  mental  fields. 
In  some  cases  there  is  improvement,  with  physical  and  men- 
tal development  and  the  formation  of  a  stable  personality. 
Periodicity  is  noticed  only  occasionally. 

Diagnosis.  —  One  should  not  confound  the  ineradicable 
relapsing  of  criminals  with  the  regular  repetition  of  similar 
criminal  acts  in  these  patients.  The  criminal  sets  fire,  kills, 
and  steals,  but  he  does  it  from  selfish  motives,  and  for  some 
definite  purpose,  perhaps  to  do  some  one  injury,  while  the 
patient  suffering  from  impulsive  insanity  is  forced  by  the 
dominating  impulse  to  the  deed  against  his  will.  Frequently 
the  patient  has  a  feeling  that  the  action  is  inconsistent,  un- 
natural, and  morbid.  Compulsive  insanity  is  distinguished 
by  the  fact  that  the  patients  do  not  commit  deeds  that  are 
in  their  minds;  they  often  have  an  abhorrence  of  them  and 
fear  that  they  may  yield  to  something  which  really  does  not 
exist.  In  impulsive  insanity  there  is  apt  to  be  associated 
with  the  idea  of  the  morbid  act  a  feeling  of  desire  and 
eagerness  for  its  performance,  and  the  patients  cannot  re- 
main quiet  until  it  is  done.  The  performance  of  the  act  is 
immediately  followed  by  a  feeling  of  relief,  while  failure 
brings  disappointment. 

Treatment.  —  The  treatment  of  impulsive  insanity  natu- 
rally lies  in  the  education  of  the  patients,  which  must  be 
adapted  to  individual  cases  and  carefully  conducted,  with 
proper  regard  for  the  physical  development.  It  is  of  great- 
est importance  that  the  patients  do  not  become  addicted  to 
the  use  of  alcohol.  There  are  some  cases  which,  for  the  pro- 
tection of  society,  need  to  be  confined  in  an  institution  where 
they  can  be  educated  to  lead  a  useful  life. 


510  FORMS   OF   MENTAL   DISEASE 


F.   Contrary  Sexual  Instincts  ' 

This  psychopathic  state,  which  received  its  name  from 
Westphal,  refers  to  those  sexual  propensities,  appearing 
mostly  in  youth,  exhibited  by  individuals  of  the  same  sex 
for  each  other,  with  an  indifference  or  even  an  abhorrence 
of  the  opposite  sex.  The  condition  has  also  been  well 
described  by  Krafft-Ebing,  Moll,  and  Schrenk-Notzing. 

Etiology.  — ■  The  contrary  sexual  instincts  are  far  more 
prevalent  among  men.  It  is  an  uncommon  condition,  the 
cases  reported  to  date  numbering  but  a  few  hundred, 
although  homosexual  patients  maintain  that  it  is  by 
no  means  rare.  Ulrichs,  in  his  own  morbid  experience, 
claims  to  have  encountered  two  hundred  cases.  It  is 
more  prevalent  in  certain  employments,  such  as  among 
decorators,  waiters,  ladies'  tailors;  also  among  theatrical 
people.  Moll  claims  that  women  comedians  are  regularly 
homosexual. 

The  condition  develops  from  a  state  of  degeneracy.  It 
is  a  view  of  Krafft-Ebing,  emphasized  by  the  statements 
of  the  patients  themselves,  that  the  peculiar  perversion  of 
the  sexual  impulse  is  congenital.  Schrenk-Notzing,  on 
the  other  hand,  lays  some  stress  upon  accidental  factors 
which  happen  to  exert  an  influence  upon  the  sexual  feel- 
ings long  before  the  age  of  sexual  development,  such  as 
the  intercourse  of  naked  boys  while  bathing,  wrestling,  etc. 
Sometimes  passionate  friendships  exist  among  young  chil- 
dren who  are  still  ignorant  of  the  sexual  differences.     But 

1  Westphal,  Archiv  f.  Psy.,  II,  1. 
v.  Krafft-Ebing,  Psychopathia  Sexualis,  1900. 
Moll,  Die  contrare  Sexualempfindung,  1891. 

Schrenk-Notzing,  Die  Suggestionstherapie  bei   krankhaften  Erachei- 
nungen  des  Geschlectssinnes,  1892. 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  511 

it  is  only  with  the  abnormal  child  that  such  accidental 
influences  upon  the  early  sensual  feelings  can  have  any 
power  in  the  later  development  of  the  sexual  impulses.  It 
seems  most  probable,  then,  that  the  morbidity  of  the  con- 
dition depends  not  upon  impulses  which  are  perverted 
from  the  onset,  but  upon  a  characteristic  tendency  origi- 
nating in  a  hereditary  state  of  degeneracy. 

Symptomatology.  —  Sexual  impulses  develop  early  and 
usually  to  a  marked  degree,  sometimes  leading  to  onanism. 
The  natural  heterosexual  impulses  may  have  developed 
first,  being  displaced  later  by  stronger  morbid  tenden- 
cies. The  patients,  both  in  the  waking  and  dream  states, 
experience  pleasurable  sexual  feelings  only  in  connec- 
tion with  their  own  sex.  Attempts  at  natural  sexual 
intercourse  are  unsuccessful,  or  accomplished  only  with 
difficulty.  Close  associations  are  usually  formed  with 
some  individuals  of  the  same  sex,  which  usually  develop 
into  passionate  friendship,  with  extravagant  display  of 
affection,  letter  writing,  sending  gifts  and  flowers,  and 
exhibitions  of  jealousy.  This  frequently  extends  to  kiss- 
ing, embracing,  and  occasionally  to  masturbation  and 
other  forms  of  sexual  perversion,  but  rarely  to  pederasty. 
In  these  friendships  the  physical  and  mental  superiority 
of  one  individual  over  another  may  aid  in  arousing  the 
sexual  feelings.  Usually  both  individuals  are  homosexual, 
but  sometimes  the  patient  desires  intercourse  only  with 
a  normal  individual.  Frequent  changes  of  the  affection, 
with  disruption  of  these  friendships,  often  occur,  showing 
the  fickleness  of  the  patients,  though  in  some  cases  such 
relationships  are  maintained  for  years.  Differences  in 
social  rank  is  of  less  importance  than  in  normal  individ- 
uals. A  few  patients  of  the  better  classes  are  attracted 
by  mechanics,  and  especially  by  soldiers. 


512  FORMS  OF  MENTAL  DISEASE 

The  patients  usually  remain  unmarried.  Those  who  do 
marry,  either  in  the  hope  of  overcoming  their  perverse 
tendencies  or  from  the  desire  to  have  children,  are  usually 
true  to  their  marital  duties,  except  in  the  matter  of  sexual 
intercourse.  Some  indulge  occasionally,  but  most  of  them 
regularly,  in  homosexual  intercourse. 

Other  symptoms  indicative  of  a  morbid  constitutional 
basis  are  usually  present,  especially  the  physical  stigmata. 
Judgment  is  usually  unimpaired,  as  well  as  the  ability  to 
comprehend,  but  there  is  an  increased  sense  of  fatigue, 
lack  of  perseverance  with  mental  work,  and  a  tendency  to 
dream.  Imagination  is  prominent  and  interferes  with  the 
capacity  for  purely  rational  activity.  Some  are  especially 
endowed  in  an  artistic  way,  being  good  musicians  and 
artists;  but  they  also  possess  a  keen  sense  of  appreciation 
of  their  abilities.  Mental  weakness  may  exist.  Many 
patients  have  an  insight  into  the  morbidness  of  their  im- 
pulses, and  defend  themselves  on  the  ground  that  the 
impulses  are  the  natural  and  involuntary  product  of  their 
constitution.  In  the  emotional  life  they  present  irritability, 
are  sensitive,  moody,  and  impressionable,  often  timid,  and 
given  to  passionate  outbursts  of  feeling.  In  actions  they 
appear  effeminate,  vain,  pliable,  unstable,  and  are  some- 
times sluggish.  They  are  often  careless  about  their  work, 
easily  distractible,  and  untrustworthy.  The  sexual  im- 
pulses are  apt  to  gain  control  over  them,  causing  neglect 
of  business.  Fetichism  and  other  perversities  may  also  be 
present. 

The  condition  of  psychic  hermaphroditism  is  occa- 
sionally present,  when  sexual  feelings  are  exhibited  toward 
both  sexes,  though  usually  stronger  toward  one  sex  than 
the  other.  Where  homosexuality  is  very  pronounced,  the 
individual  may  experience  a  change  of  personality,  a  man 


CONSTITUTIONAL  PSYCHOPATHIC  STATES  513 

becoming  feminine  in  manner,  gait,  and  countenance.  He 
becomes  affected  in  manner,  vain,  coquettish,  takes  great 
pains  with  his  personal  appearance,  desires  to  be  in  fashion, 
wears  flowers,  and  uses  cosmetics.  Some  develop  a  fond- 
ness for  women's  employment,  do  needlework,  arrange 
their  rooms  after  the  fashion  of  a  woman's  boudoir,  and 
they  may  even  dress  in  women's  clothes,  padding  the  hips 
and  breast,  talk  in  a  falsetto  voice,  and  in  every  possible 
way  simulate  feminine  traits.  Early  evidences  of  such 
traits  may  make  their  appearance  in  childhood.  A  few 
patients  present  physical  characteristics  indicative  of  the 
opposite  sex;  men  are  beardless,  possess  high-pitched, 
light  voices,  have  soft  white  skin,  with  a  more  marked 
pannicus  adiposus  and  well-developed  mammae;  while  the 
homosexual  females  have  a  deep,  coarse  voice  and  show  a 
tendency  to  grow  beards.  The  former  are  called  by  Krafft- 
Ebing  androgyny,  and  the  latter  gynandry.  Hermaphro- 
ditism has  never  been  encountered  in  homosexual  individ- 
uals. 

The  course  of  the  disease,  which  usually  reaches  its  full 
development  between  twenty-five  to  thirty-five  years  of 
age,  is  always  prolonged.  In  the  acquired  homosexuality 
there  is  often  a  long  struggle  before  the  patient  becomes 
a  confirmed  pervert.  The  homosexual  tendencies  may 
appear  periodically,  with  or  without  accompanying  states 
of  general  excitement. 

Diagnosis.  —  It  is  not  a  difficult  matter  to  identify 
homosexual  patients  where  there  has  been  a  marked  trans- 
position of  the  traits  characteristic  of  the  sexes.  Yet 
normal  sexual  instincts  may  exist  in  spite  of  such  a  trans- 
position. Usually  the  condition  becomes  known  to  the 
physician  only  through  the  communication  of  the  patient. 
It  is  necessary  to  distinguish  between  contrary  sexual  in- 

2l 


514  FORMS  OF  MENTAL   DISEASE 

stincts  and  mere  practice  of  homosexual  acts,  the  latter 
being  pure  perversity,  as  practised  among  prisoners,  etc., 
who  return  to  normal  sexual  relations  upon  gaining  free- 
dom. 

Prognosis.  —  The  prognosis  is  more  favorable  than  is  usu- 
ally thought.  Very  many  cases  improve,  and  some  even 
recover  under  the  influence  of  treatment. 

Treatment.  —  The  most  successful  method  of  treat- 
ment is  through  the  use  of  hypnotic  suggestion.  This 
is  directed  first  against  the  increased  sexual  excitability 
and  masturbation  which  is  frequently  present;  next  it  is 
applied  to  the  insensibility  of  the  patient  toward  his  own 
sex,  and  finally  in  creating  an  excitability  toward  the 
opposite  sex  and  a  tendency  to  heterosexual  intercourse. 
The  hypnotic  influence  over  the  patient,  dealing  as  it  does 
with  a  deeply  rooted  habit,  is  acquired  slowly  and  with 
difficulty.  Schrenk-Notzing  lays  great  stress  upon  regular 
natural  intercourse,  but  excessive  coitus  must  be  avoided, 
because  it  may  have  an  injurious  effect  upon  the  self- 
confidence.  Treatment  directed  at  the  general  nervous 
condition  is  also  of  importance,  and  should  include  the 
establishment  of  a  routine  in  the  physical  and  mental 
life,  with  attention  to  the  diet,  exercise,  and  relaxation. 
One  should  remember  that  even  though  marked  improve- 
ment or  recovery  takes  place,  the  original  defective  basis 
still  remains. 


XIV.   PSYCHOPATHIC  PERSONALITIES 

Those  psychopathic  conditions  which  develop  on  a  mor- 
bid constitutional  basis  include  an  extensive  borderland 
between  pronounced  morbid  states  and  mere  personal 
eccentricities  which  are  wont  to  be  regarded  as  normal. 
We  consider  personal  deviations  from  the  regular  course 
of  mental  development  as  morbid  only  when  they  are  of 
special  consequence  to  the  physical  and  mental  life;  but 
the  distinction  is  one  of  degree  and  is  to  a  certain  extent 
arbitrary. 

There  is  a  considerable  group  of  such  morbid  conditions 
which  may  be  properly  regarded  as  mental  deformities. 
They  are  not  characterized  by  any  definite  disease  process, 
but  rather  by  a  general  deviation  from  the  normal  mental 
life.  Our  discussion  of  this  group  will  be  limited  to  conspicu- 
ous types  which  are  of  special  interest  to  the  psychiatrist. 

A.   Born  Criminals 

The  French  alienists  were  the  first  to  call  attention  to  the 
fact  that  there  was  a  form  of  insanity  in  which  the  dis- 
order was  limited  to  the  fields  of  the  feelings  and  the  con- 
duct. In  1835,  Pritchard  grouped  together,  under  the  name 
of  "Moral  Insanity,"  those  diseases  in  which  there  existed 
a  perverse  state  of  the  feelings,  temperaments,  dispositions, 
habits,  and  actions,  while  the  intellectual  functions  pre- 
sented no  apparent  abnormalities.  The  possibility  of  a  cir- 
cumscribed impairment    of   the  morals  was  combated  by 

515 


516  FORMS  OF  MENTAL  DISEASE 

pointing  out  the  correlation  between  the  different  phases 
of  the  mental  life  and  the  presence  of  concurrent  intellectual 
abnormalities, hence  "  Moral  Insanity"  ceased  to  be  regarded 
as  a  separate  disease  and  came  to  be  classed  as  one  of  the 
sub-forms  of  imbecility.  One  of  the  causes  of  this  change 
of  attitude  was  the  supposedly  demoralizing  effects  of  the 
doctrine  on  criminal  law. 

Daily  experience  teaches  us  that  the  intellect  and  the 
emotions  develop  more  or  less  independently  of  each  other. 
There  are,  undoubtedly,  men  with  conspicuous  mental 
endowment  who  are  morally  bad  and  vice  versa.  We  must 
admit,  however,  that  the  complete  independence  of  the 
separate  fields  does  not  obtain.  Even  in  congenital  emo- 
tional indifference  there  is  always  present  a  certain  im- 
pairment of  intellectual  capacity.  But  unquestionably 
there  is  a  large  number  of  individuals  in  whom  the  inade- 
quate development  of  the  moral  feelings  is  more  conspicuous 
than  that  of  the  intellect. 

The  doctrine  of  "  Moral  Insanity  "  has  received  new  mean- 
ing through  the  activities  of  Lombroso  and  the  Italian 
positivistic  school  in  the  attempt  to  describe  and  differen- 
tiate the  born  criminal  —  "Delinquente  nato."  According 
to  Lombroso  about  twenty-five  per  cent,  of  criminals,  and  a 
still  higher  percentage  among  the  murderers,  carry  the 
marks  of  the  born  delinquent.  It  is  a  reasonable  hypothesis 
that  in  these  conditions  we  have  to  do  with  various  grades 
of  psychopathic  degeneracy.  The  lighter  forms  may  be 
scarcely  distinguishable  from  the  inadequate  moral  develop- 
ment of  normal  life.  But  on  the  other  hand,  there  are  per- 
sons whose  shocking  moral  incapacity  clearly  indicates 
morbid  degeneracy.  At  the  present  time  there  is  a  certain 
justification  for  calling  the  severest  forms  of  criminal  en- 
dowment "Moral  Insanity"  or  "Moral  Imbecility."     But 


PSYCHOPATHIC  PERSONALITIES  517 

more  exact  characterization  of  the  various  conditions 
which  have  hitherto  been  collectively  designated  by  this 
term  would  help  to  clarify  the  matter;  for  instance,  it 
would  be  advisable  to  differentiate  between  those  who 
suffer  from  constitutional  excitement,  the  unstable  and  the 
morbid  swindler,  and  the  group  which  we  are  here  describing 
and  which  is  characterized  in  general  by  moral  stupidity. 

Etiology.  —  The  general  causes  of  this  type  of  degeneracy 
are  practically  the  same  as  those  which  we  have  come  to 
regard  as  the  causes  of  degeneracy  itself.  Alcoholism  in 
the  parents  easily  stands  first.  Among  two  hundred  in- 
mates of  a  reform  school  seventy-eight  had  drunken  fathers; 
five,  drunken  mothers;  and  in  two  cases  both  parents  were 
drunkards.  There  were  also  twenty-four  cases  in  which 
parents  suffered  from  mental  disturbances,  twenty-six 
from  epilepsy,  and  many  more  from  other  nervous  diseases. 
The  correlation  between  illegitimacy  and  born  criminals 
is  partially  accounted  for  by  the  presence  of  defective  hered- 
ity and  of  alcoholism  in  the  parents. 

These  facts,  together  with  the  prevalence  of  stigmata  and 
the  unresponsiveness  of  the  genuine  criminal  nature  to  all 
educational  influences,  indicates  the  existence  of  a  certain 
group  of  cases  with  abnormal  endowment  gradually  merg- 
ing into  disease.  Moreover,  some  of  these  patients  after 
a  long  criminal  career  develop  severe  psychoses  which  lead 
to  deterioration,  especially  the  paranoid  forms  of  dementia 
prsecox. 

Symptomatology. — The  intellect  of  these  patients  is  toler- 
ably developed  within  the  limits  of  practical  life.  They 
comprehend  well,  acquire  a  certain  amount  of  knowledge 
and  experience,  which  they  may  exploit  with  some  crafti- 
ness ;  they  show  no  defect  of  memory  and  are  fairly  logical 
in  their  thought.    But  their  views  are  narrow.    They  cannot 


518  FORMS  OF  MENTAL  DISEASE 

perform  exacting,  intellectual  work  and  are  unable  to  de- 
velop any  coherent  conception  of  life.  Experts  on  criminal 
natures  have  demonstrated  a  decided  lack  of  comprehen- 
sive reflection  and  foresight.  Born  criminals  do  not  feel  the 
need  of  reflecting  beyond  the  present  and  the  more  imme- 
diate future. 

Even  in  early  youth  there  are  conspicuous  moral  dejects, 
such  as  a  lack  of  sympathy,  shown  by  barbarous  cruelty  to 
animals,  malicious  teasing,  illtreatment  of  their  playmates, 
and  general  unresponsiveness  to  kindness.  Later  there 
develops  pronounced  selfishness  without  sense  of  honor  or 
proper  affection  for  parents,  brothers,  and  sisters.  Here 
belong  those  monstrous  children  who  even  at  the  tenderest 
age  try  to  murder  the  members  of  their  family  for  trivial 
reasons,  and  then  report  in  a  stupid,  matter-of-fact  way  the 
details  of  their  plans,  and  show  obvious  regret  at  their 
failure.  Attempts  at  education  are  fruitless,  since  the 
most  important  incentives  —  love  and  ambition  —  are  lack- 
ing. Force  alone  is  able  to  suppress  the  manifestations  of 
their  unbridled  selfishness,  but  it  is  soon  met  by  duplicity, 
cunning,  deceit,  callousness,  stubbornness,  and  a  disposition 
to  lie.  Development  throughout  is  selfish.  Patients  mani- 
fest affection  toward  parents,  relatives,  and  companions 
only  when  they  anticipate  some  advantage  from  it.  The 
egotism  expresses  itself  in  vanity,  braggadocio,  peevishness, 
love  of  idleness,  excesses,  foolish  prodigality,  and  often 
in  weak  sentimentality.  Usually,  there  is  little  resistance 
to  temptation  and  sudden  impulses,  and  there  is  great 
emotional  irritability,  vindictiveness,  unreliability,  insta- 
bility, and  susceptibility  to  alcohol. 

It  is  evident  that  such  an  endowment  will  lead  almost 
necessarily  to  a  criminal  career.  It  usually  begins  with 
truancy,  loitering,  begging,  and  petty  larcenies,  oftentimes 


PSYCHOPATHIC  PERSONALITIES  519 

in  connections  with  gangs,  and,  in  females,  with  prostitution. 
Often  this  leads  to  commitment  to  reform  schools.  Such 
children  of  the  well-to-do  classes  shock  their  parents  at  an 
early  age  by  vulgarity,  lying,  persistent  laziness,  petty  lar- 
cenies, and  peculations.  They  wander  from  one  teacher 
to  another,  always  with  the  same  lack  of  success,  until 
finally  it  becomes  impossible  to  protect  them  from  the  re- 
sults of  their  conduct. 

The  further  life  of  these  morally  incapable  personalities 
is  a  constant  conflict  with  society.  They  soon  find  them- 
selves thoroughly  out  of  harmony  with  any  social  environ- 
ment in  which  they  are  located.  But  they  are  wholly 
unable  to  appreciate  that  it  is  their  own  actions  which  neces- 
sitate their  being  condemned  to  pass  their  lives  in  prisons 
and  penitentiaries.  They  rather  consider  themselves  mar- 
tyrs who  are  cruelly  persecuted,  while  others,  no  better  than 
they,  live  in  honor  and  wealth.  They  regularly  fail  to  com- 
prehend the  probable  outcome  of  their  lives.  They  are  con- 
vinced that  it  will  be  possible  for  them  to  succeed,  even 
when  they  are  determined  to  return  immediately  to  their 
old  ways.  Many  submit  with  cringing  docility  to  imprison- 
ment, while  others  even  in  confinement  continue  their 
struggle  against  the  regulations  of  society  by  insubordina- 
tion, deceit,  and  treachery.  But  as  a  rule  they  are  cowardly 
and  less  inclined  to  open  violence  than  to  passive  opposition 
and  to  treachery.  They  are  frequently  hypochondriacal, 
and  there  is  often  an  increased  susceptibility  to  bodily  pain. 
Their  inaccessibility  to  friendly  advances  is  quite  noticeable. 

From  this  class  of  morally  defective  individuals  the 
majority  of  " professional  criminals"  originate.  These 
criminals  derive  increasing  pleasure  from  conflicts  with  the 
laws,  pride  themselves  on  their  performances,  and  show  a 
conscious  effort  to  develop  themselves  for  their  art.     Thus 


520  FORMS  OF  MENTAL  DISEASE 

there  develop  criminal  "specialists,"  who  become  exceed- 
ingly cunning  and  skilful.  But  it  is  a  notable  fact  that  in 
their  criminal  acts  they  often  show  an  astonishing  degree  of 
heedlessness  and ,  lack  of  foresight.  Evidences  of  pro- 
nounced physical  degeneracy  often  accompany  the  criminal 
natures.  There  are  no  definite  and  inevitable  deviations, 
but  there  is  a  considerable  group  of  signs  of  degeneracy, 
which  show  unmistakably  that  confirmed  criminals  often 
possess  an  inferior  physical  endowment.  The  number  and 
variety  of  these  signs  are  certainly  more  apparent  in  crimi- 
nals than  in  the  general  population.  This  fact  of  itself 
naturally  proves  nothing  in  an  individual  case.  A  given 
person  may,  therefore,  be  mentally  sound  in  spite  of  numer- 
ous signs  of  degeneracy.  On  the  other  hand,  we  would  ex- 
pect a  larger  percentage  of  mental  deviations  in  men  of  that 
sort  than  in  those  who  present  no  stigmata.  To  be  sure 
they  do  not  need  to  be  criminals  on  that  account.  Rather, 
the  born  criminal  is  only  one  of  the  forms  in  which  degen- 
eracy expresses  itself. 

Diagnosis.  —  It  is  exceedingly  difficult  to  draw  a  sharp 
line  between  health  and  disease.  Hence,  judges  of  the 
court  especially  combat  the  assumption  of  a  "  moral  im- 
becility." But  the  existence  of  the  moral  incapacity  ex- 
tending back  into  early  youth,  in  spite  of  satisfactory 
intellectual  development  and  the  complete  unresponsiveness 
of  the  patient  to  all  moral  influences,  justify  the  assumption 
of  a  morbid  personality.  Moreover,  the  existence  of  numer- 
ous and  definite  signs  of  physical  degeneracy,  as  well  as  the 
history  of  injurious  prenatal  influences,  such  as  alcoholism 
or  mental  disease  in  the  parents,  are  significant,  but  in  any 
individual  case  they  are  of  value  only  as  indicating  the 
necessity  of  a  careful  scientific  examination  of  the  mental 
condition,  and  are  not  proof  of  disease.    It  is  a  notable 


PSYCHOPATHIC   PERSONALITIES  521 

fact  that  many  of  these  patients  fail  to  show  any  striking 
disturbances  during  imprisonment  or  while  confined  in  in- 
stitutions, but  their  great  incapacity  at  once  becomes  evi- 
dent as  soon  as  they  are  released  and  exposed  to  the 
numerous  vicissitudes  of  life. 

Treatment.  —  The  treatment  of  born  criminals  unfor- 
tunately offers  little  opportunity  and  still  less  prospect  of 
success.  If  a  quiet,  rigid,  but  at  the  same  time  kindly 
education  in  a  limited  sphere,  preferably  under  psychiatric 
supervision,  does  not  succeed,  the  individual  cannot  be 
prevented  from  entering  a  criminal  career.  Lombroso  has 
advocated  the  view  that  many  of  these  persons  under  favor- 
able conditions  need  not  come  into  conflict  with  the  law,  but 
may  gratify  their  criminal  tendencies  in  other  and  incon- 
spicuous ways.  This,  however,  is  true  only  of  the  lighter 
forms,  which  closely  approximate  health.  Baer  reports  that 
occasionally  children  who  were  originally  emotionally  de- 
ficient have  later  in  life  improved  considerably.  It  is  also 
a  well-known  fact  that  some  of  the  criminal  tendencies 
that  appear  early  in  fife,  such  as  the  propensity  to  he,  to 
steal,  and  to  cruelty,  can  almost  completely  disappear  as 
the  patient  matures  mentally.  In  later  life  the  best  that 
one  can  do  is  to  compel  the  person  to  follow  a  regular  oc- 
cupation under  proper  control,  to  choose  proper  associates, 
and  finally  to  abstain  from  alcohol  and  sexual  excesses. 
Unfortunately,  this  can  be  carried  out  successfully  only 
in  the  light  cases. 

B.   The  Unstable 

The  " unstable,"  as  the  French  call  them,  constitute  a 
second  large  group  of  psychopathic  personalities  which  are 
characterized  by  a  weakness  of  will  in  all  their  activities. 

Symptomatology. — The  intellectual  endowment  may  be 


522  FORMS  OF  MENTAL  DISEASE 

very  good,  but  is  often  only  mediocre.  Some  patients 
astonish  one  by  their  rapidity  of  comprehension,  their  ease 
of  committing  things  to  memory,  and  their  ability  to  ex- 
press themselves.  Patients  are  often  keen  observers, 
quickly  recognizing  the  defects  and  peculiarities  of  their  en- 
vironment, are  vivacious  and  understand  thoroughly  how  to 
use  their  information  to  the  best  advantage.  On  the  other 
hand,  they  lack  altogether  energy  for  continuous  and  satis- 
factory work.  They  start  out  zealously,  but  soon  grow 
weary  and  are,  therefore,  unable  to  complete  any  course  of 
education.  They  never  probe  to  the  bottom  of  things  and 
their  knowledge  is  superficial  and  fragmentary.  Knowledge 
is  often  readily  acquired  but  is  not  elaborated  and,  there- 
fore, is  quickly  forgotten.  At  school  their  talents  some- 
times arouse  great  expectations,  which  are  never  fulfilled 
because  of  their  inconstancy  and  unreliability.  It  is  often 
said  of  such  children, "  They  could  do  much  better  if  they 
only  would,"  but  unfortunately  they  lack  the  power  to  will. 

Higher  intellectual  development  is  always  defective. 
Conception  is  confused  and  indistinct,  judgment  is  im- 
mature and  onesided,  and  the  understanding  of  life  un- 
developed and  short-sighted.  Their  interests  center  on 
sports  and  on  frivolous  pleasures,  and  they  do  not  respond 
to  more  serious  matters.  They  often  show  a  propensity 
to  dream,  to  poetical  or  dramatic  efforts,  etc.,  but  they  are 
never  earnest  or  thorough. 

In  emotional  attitude  the  patients  show  abrupt  changes,  at 
times  being  elated  and  confident,  and  at  others  spiritless, 
sensitive,  or  pessimistic.  They  are  very  easily  aroused  to 
enthusiasm,  and  as  readily  disheartened.  There  is  usually 
an  increased  irritability,  sensitiveness,  and  peevishness. 
They  are  offended  and  dispirited  upon  slight  provocation, 
are  suspicious  and  prejudiced,  but  one  can  easily  put  them 


PSYCHOPATHIC  PERSONALITIES  523 

into  good  humor  again.  Very  often  their  relations  with  then- 
relatives  become  strained.  The  patients  often  become 
dissatisfied  and  embittered,  the  cause  of  which  in  their 
opinion  never  lies  in  their  own  behavior,  but  in  the  unkind- 
ness  of  their  people.  Although  they  are  generally  harmless 
and  good  natured,  they  are  dominated  by  the  most  pro- 
nounced selfishness.  Their  own  welfare  is  their  chief  con- 
cern, while  they  show  little  interest  in  their  environment 
and  even  less  sympathy.  They  are  not  inclined  to  sub- 
mit to  privation,  but  demand  comfort  and  luxuries,  and 
regard  all  restrictions  as  gratuitous  insult.  They  often 
show  vanity  in  the  effeminate  care  of  their  personal  appear- 
ance, their  affected  utterance,  and  tendency  to  braggadocio. 
The  patients'  lack  of  perseverance,  of  power  of  resistance, 
and  energy  usually  becomes  evident  as  soon  as  they  are 
deprived  of  home  influences.  At  school  they  are  con- 
sidered pliable,  unstable,  and  easily  led  off  into  foolish 
pranks,  but  they  are  susceptible  to  education,  which,  how- 
ever, does  not  last.  As  soon  as  they  have  to  stand  on  their 
own  feet,  they  are  helpless.  Since  work  is  not  agreeable, 
they  often  change,  hoping  to  find  an  easier  occupation. 
They  lack  punctuality,  neglect  their  business,  do  not  work 
full  hours,  and  allow  little  things  to  interfere  with  ful- 
filling their  obligations.  They  excuse  their  unproductive- 
ness in  various  ways.  In  one  place  the  work  is  stultifying, 
in  another  too  strenuous,  the  shop  is  unsanitary,  the  fore- 
men are  too  severe,  etc.  Conditions  of  emotional  excite- 
ment are  aroused  by  ridiculously  trifling  occurrences  and 
prevent  the  patients  from  working ;  under  no  circumstances 
can  they  continue  work,  they  must  cool  down,  and  must 
seek  diversion  by  going  to  the  theatre.  They  are  often  hypo- 
chondriacal, are  deeply  concerned  for  their  health,  feel 
exhausted,  have  headaches,  or  a  feeling  of  faintness  as  soon 


524  FORMS  OF  MENTAL  DISEASE 

as  they  are  set  to  work.  Hence,  they  are  frequently  dis- 
charged as  useless,  or  at  most  are  tolerated  as  unpaid  as- 
sistants, and  are  wholly  incapable  of  obtaining  an  indepen- 
dent livelihood. 

They  are  usually  not  ashamed  of  this  state  of  affairs.  They 
see  no  impropriety  in  being  supported  by  others,  and  believe 
circumstances  justify  their  conduct.  Even  though  they 
earn  nothing,  they  are  careless  with  their  money,  buying 
useless  articles  in  large  amounts  without  thought  of  the 
future. 

They  readily  yield  to  temptation.  If  placed  under 
guardianship,  they  become  slack,  indolent,  and  unproduc- 
tive, but  they  lead  their  useless  lives  without  gross  dis- 
turbances, tend  to  fill  them  with  loafing  and  useless  fads, 
take  cures  when  not  sick,  and  seek  recreation  when  not 
weary.  In  bad  company,  they  give  themselves  up  to  sexual 
extravagances,  get  diseased,  and  begin  to  drink  and  gamble. 
Under  these  influences  they  sometimes  do  very  questionable 
things  and  even  perform  criminal  acts.  Such  patients 
sometimes  develop  the  picture  of  "  pseudo-dipsomania. " 
They  may  abstain  for  months  and  then  upon  some  occasion 
when  their  weak  will  is  overpowered,  they  begin  to  drink  and 
continue  drinking  until  thoroughly  intoxicated  and  their 
money  is  all  gone.  It  is  not  their  emotional  condition 
that  impels  the  patients  to  drink,  but  mere  incidents,  such 
as  an  intimate  friend  or  a  farewell  banquet.  The  de- 
bauches are  not  periodical,  but  are  determined  by  external 
circumstances.  Moreover,  the  patients  are  not  excited  by 
the  alcohol,  but  are  simply  intoxicated. 

Lighter  grades  of  this  weakness  of  will  are  very  common. 
A  very  large  proportion  of  those  whom  Aschaffenburg  calls 
"habitual  criminals,"  and  particularly  a  large  number  of 
tramps,  mendicants,  and  even  prostitutes  belong  to  this 


PSYCHOPATHIC  PERSONALITIES  525 

group.  The  instability  first  becomes  evident  as  soon  as 
these  individuals  encounter  some  difficulty  in  their  lives. 
Investigation  shows  that  a  large  number  of  vagabonds  are 
forced  into  their  life  by  their  congenital  instability  and  not 
by  unusual  circumstances.  The  same  condition  is  clearly 
shown  to  exist  in  the  offspring  of  well-to-do  parents,  who, 
notwithstanding  an  apparently  good  endowment  and  good 
education,  continue  wholly  unstable.  One  rarely  fails  to 
find  in  these  families  traces  of  degeneracy. 

Diagnosis. — -The  gradual  appearance  of  the  symptoms 
of  instability,  as  the  patients  attempt  to  undertake  the 
duties  of  life,  resembles  somewhat  the  picture  of  dementia 
prcBcox.  But  without  question  they  are  two  totally  different 
conditions.  Instability  often  leads  to  idleness  and  aban- 
donment of  certain  lines  of  work,  but  never  to  dementia. 
The  condition  of  the  patients  remains  essentially  the  same 
as  it  was  in  youth;  they  are  not  dull  and  apathetic,  but 
only  afraid  of  work.  They  retain  their  hobbies  and  always 
feel  the  necessity  of  passing  the  time  in  some  agreeable 
way.  Notwithstanding  their  perverted  and  onesided  ap- 
prehension, they  develop  neither  delusions  nor  hallucina- 
tions. Finally,  the  patients  are  natural  in  their  manners; 
their  will  is  weak  and  yielding,  but  never  shows  eccen- 
tricities. 

Other  forms  of  the  insanity  of  degeneracy  sometimes 
resemble  the  unstable;  for  instance,  the  increased  sugges- 
tibility reminds  one  of  hysteria.  The  unstable  do  not  show 
the  extensive  influence  of  the  emotional  states  upon  the 
physical  processes,  although  there  are  occasional  hysterical 
symptoms.  Like  the  born  criminals  the  unstable  present 
great  susceptibility  to  temptations,  distaste  for  work, 
superficial  intellectual  work,  lack  of  foresight,  selfishness, 
and  are  often  enough  impelled  to  criminal  careers.    Never- 


526  FORMS  OF  MENTAL  DISEASE 

theless,  it  is  better  to  distinguish  the  two  forms  of  psycho- 
pathic personalities.  The  unstable  lack  the  passion  and 
persistency  characteristic  of  the  born  criminal ;  there  is  no 
trace  of  the  independent  criminal  will  and  of  professional 
warfare  against  social  order.  When  the  unstable  commit 
crimes,  they  are  the  result  of  opportunity  and  temptation, 
and  are  limited  to  actions  which  demand  neither  resolution 
nor  energy. 

Treatment.  —  Since  this  disease  represents  a  form  of 
degeneracy,  the  treatment  is  limited.  The  value  of  edu- 
cational measures  in  individual  cases,  such  as  afforded  by 
a  strict  regimen  in  the  performance  of  duties  and  develop- 
ment of  physical  capacity  for  work,  depends  on  the  severity 
of  the  disturbance.  In  later  years  sanitarium  life  may  be 
helpful,  where  it  is  possible  to  remove  all  sorts  of  morbid 
inhibitions  and  to  direct  employment.  Unfortunately,  the 
patients  rarely  possess  sufficient  determination  to  submit 
to  compulsion  for  any  length  of  time.  In  some  cases  total 
abstinence  from  alcohol  causes  great  improvement.  Under 
favorable  circumstances  it  is  sufficient  if  one  is  able  to 
protect  the  patients  against  relapses  for  some  time. 

C.  The  Morbid  Liar  and  Swindler 

The  morbid  liar  and  swindler  —  the  "pseudologia  phan- 
tastica  "  —  has  been  described  by  Delbrueck.  This  disorder 
consists  of  a  morbid  hyperactivity  of  the  imagination,  in- 
accuracy of  memory,  and  a  certain  instability  of  the  emotions 
and  volitions. 

Symptomatology.  —  At  first  glance  these  patients  often 
appear  specially  gifted.  They  apprehend  quickly,  easily 
comprehend  new  situations,  and  readily  acquire  special 
information,  such  as  geographical  and  historical  data, 
citations  from  poets,  and  even  foreign  languages.    They  can 


PSYCHOPATHIC  PERSONALITIES  527 

converse  fluently  on  the  most  varied  subjects,  have  heard 
of  almost  everything,  and  are  sure  in  their  judgments. 
They  thus  give  the  impression  of  being  cultured  and  well 
read,  but  in  reality  their  knowledge  is  very  superficial  and 
made  up  of  isolated,  incoherent  scraps,  and  a  mixture  of 
details,  which  are  insufficiently  comprehended  and  elabo- 
rated and  at  times  even  falsified.  Their  thought  lacks 
system,  order,  and  coherence;  their  judgment  is  immature 
and  their  conception  of  fife  shallow  and  insincere. 

There  is  associated  with  the  susceptibility  to  new  impres- 
sions an  extraordinary  mobility  of  the  content  of  memory. 
But  both  of  these  symptoms  are  an  expression  of  one  and 
the  same  fundamental  disturbance;  namely,  an  increased 
lability  of  the  psychic  processes.  Recollections,  moods, 
wishes,  and  accidental  impulses  alter  and  color  the  experi- 
ences of  life  in  various  ways,  so  that  before  long  there 
appears  an  inextricable  mixture  of  truth  and  fiction.  In 
morbid  liars  these  fabrications  and  falsifications  of  memory 
appear  on  a  large  scale.  At  first  there  may  be  an  indistinct 
feeling  of  uncertainty  as  to  their  statements,  but  very 
soon  the  actual  and  invented  details  become  so  mixed 
that  the  patients  themselves  are  no  longer  able  to  account 
for  their  real  origin. 

The  specially  characteristic  feature  of  morbid  lying  is  the 
satisfaction  which  the  patients  derive  from  wilful  falsifications 
of  memory  —  the  ujoy  of  lying."  They  are  very  apt  to  em- 
bellish the  most  unimportant  statements  with  alterations 
and  additions ;  indeed,  they  often  cannot  tell  a  story  twice 
alike.  The  activity  of  their  imagination  enables  them  to 
fancy  unreal  occurrences  in  a  dreamlike  fashion ;  they  think 
of  themselves  as  participating  in  them,  and  finally  they 
recount  them  as  actual  facts,  clothed  in  varying  forms. 

In  this  way  patients  come  to  involve  themselves  in  a  maze 


528  FORMS  OF  MENTAL  DISEASE 

of  statements  and  narrations  from  which  there  is  no  other 
escape  except  by  new  falsehoods.  The  most  extraordinary 
experiences  are  related  in  a  most  matter-of-fact  way,  with 
a  cautious  secrecy  or  with  outbursts  of  emotion;  such  as 
their  descent  from  royal  families,  dangerous  experiences, 
powerful  enemies,  unheard-of  incidents  like  those  encoun- 
tered in  dime  novels,  etc.  Indeed,  many  details  may  be 
borrowed  directly  from  their  reading.  The  content  of 
these  fabrications  can  change  according  to  need  or  fancy. 
Yet  some  elements  tend  to  recur.  In  spite  of  appearances 
the  patients  do  not  present  genuine  delusions.  They  know 
well  enough  that  they  are  fabricating,  but  allow  themselves 
to  be  carried  away  by  their  material,  and  keep  on  spinning 
it  out.  They  are  soon  forced  by  the  contradictions  with 
their  earlier  utterances  to  new  fabrications,  but  even  with- 
out this  they  are  unable  to  withstand  the  impulse  to  give 
full  sway  to  their  imagination  on  every  occasion.  For  the 
time  being  they  completely  forget  the  distinction  between 
reality  and  fiction.  When  confronted  with  their  lies,  they  are 
either  contrite  and  promise  to  do  better,  only  to  justify  their 
conduct  by  a  new  tissue  of  fantastic  lies;  or  they  disavow 
outright  their  early  statements,  assuming  the  attitude  of 
injured  innocence  and  declining  further  discussion.  If 
they  can  gain  a  little  time  in  this  way,  they  very  soon  aston- 
ish one  by  further  disclosures. 

In  emotional  attitude  the  patients  are  usually  high  spirited 
and  self-conscious.  They  live  from  one  day  to  another  in 
a  wholly  indifferent  manner,  have  no  care  for  anything, 
trust  their  star,  are  thoughtless,  and  are  always  devising 
jokes  and  pastimes.  At  intervals  there  are  occasional 
dramatic  outbreaks  of  despair  or  of  angry  irritability. 
Any  criticism  of  their  pretensions  is  apt  to  be  met  with 
real  excitement,  but  such  emotional  fluctuations  are  usually 


PSYCHOPATHIC  PERSONALITIES  529 

superficial  and  soon  give  way  to  the  usual  self-complacency. 
Patients  show  absolutely  no  insight,  but,  on  the  other  hand, 
consider  themselves  specially  gifted,  clever,  and  boast  most 
impressively  of  their  family  connections,  liberal  education, 
brilliant  attainments,  and  prospects.  They  lay  the  blame 
for  any  apparent  lack  of  success  upon  adverse  circumstances, 
inadequate  support,  or  the  hostility  of  relatives,  etc.  Even 
in  their  simplest  narratives,  they  are  easily  led  into  apparent 
exaggerations. 

In  conduct  patients  are  clever,  confident,  and  presump- 
tuous. They  are  uncommonly  curious,  like  to  participate  in 
everything,  and  understand  how  to  make  an  impression, 
and  to  inspire  common  people  with  confidence  and  respect. 
They  have  a  tendency  to  gossip,  to  read  much,  and  to  busy 
themselves,  but  not  persistently,  and  they  are  fond  of  pleas- 
ures, dissipations,  entertainments,  and  gay  society.  Left 
to  themselves  they  are  prone  to  live  an  irregular,  extravagant, 
and  prodigal  life,  are  exceedingly  polite,  dress  in  the  latest 
fashion,  and  lavish  their  money  on  trifles. 

With  this  sort  of  an  endowment  these  morbid  patients  are 
naturally  impelled  to  the  career  of  swindlers  and  tramps. 
The  tendency  to  swindling  of  all  kinds  appears  even  in  early 
youth.  Thirst  for  adventures  leads  patients  to  undertake 
adventurous  journeys,  during  which  they  employ  their  gift 
for  lying  to  make  credulous  people  believe  their  fabulous 
tales  concerning  themselves,  their  past  history,  and  their 
future  prospects,  and  to  lure  money  from  their  pockets. 
They  know  how  to  conceal  their  real  personality  so  that  it 
is  often  impossible  to  expose  them.  They  are  especially 
apt  to  pose  as  scions  of  a  famous  family,  who  have  been 
compelled  by  various  circumstances  to  flee  and  to  conceal 
themselves,  but  they  have  the  prospect  of  securing  great 
riches.    They  know  how  to  establish  the  probability  of  all 

2m 


530  FORMS  OF  MENTAL  DISEASE 

this  by  all  sorts  of  dodges,  such  as  forged  letters  and  papers. 
They  swindle  every  one  possible  by  relating  to  them  pathetic 
stories.  They  present  themselves  as  colleagues,  turn  up 
under  different  names,  and  use  high-sounding  titles  to  order 
merchandise  of  all  kinds.  Their  procedures  resemble  those 
of  the  ordinary  swindler,  but  it  is  noteworthy  that  these 
patients  swindle  in  reference  to  things  of  little  consequence 
and  often  get  no  advantage  out  of  their  representations. 
Many  patients  simply  wander  about  acquiring  a  livelihood 
by  irregular  but  respectable  occupations,  boast  and  lie  for 
no  other  purpose  than  the  mere  pleasure  derived  from 
their  falsehoods  and  impressions  which  they  make  on  their 
surroundings. 

Morbid  swindling  and  lying  are  also  forms  of  degeneracy. 
They  are  very  often  accompanied  by  definite  hysterical 
symptoms.  However,  they  should  not  be  regarded  simply 
as  a  type  of  hysteria,  because  they  often  occur  without 
hysterical  symptoms.  Moreover,  they  are  in  some  respects 
related  to  the  group  of  the  unstable;  indeed,  there  are  even 
transition  forms  into  that  group.  There  is  really  some 
question  as  to  whether  these  patients  should  not  be  in- 
cluded in  constitutional  excitement.  ^Tiile  it  is  probably  as 
difficult  to  draw  sharp  lines  here  as  for  other  forms  of 
degeneracy,  still  prominent  psychomotor  excitement  may 
be  the  cue.  It  is  lacking  in  morbid  swindling  and  lying. 
Great  distract  ibility,  marked  irritability,  loquacity, 
fondness  for  new  undertakings,  great  instability,  and 
restlessness  indicate  constitutional  excitement,  in  which 
fabrications  often  occur  but  are  not  necessarily  concomitant 
symptoms.  On  the  other  hand,  fondness  for  invention  of 
details,  dignified  manners,  a  great  gift  for  fabrications  un- 
accompanied by  excitement,  and  the  clever  ability  to  take 
advantage   of   credulous   persons,   are   rather  the   charac- 


PSYCHOPATHIC   PERSONALITIES  531 

teristics  of  the  born  swindler.  It  seems  of  special  impor- 
tance that  in  constitutional  excitement  the  tendency  to 
swindle  appears  at  a  certain  time  and  may  show  definite 
exacerbations,  while  in  born  swindlers  it  is  a  permanent 
personal  peculiarity.  Also,  the  occurrence  of  frequent  and 
sudden  changes  of  disposition,  especially  periods  of  causeless 
dejection  and  despair,  favors  the  diagnosis  of  constitutional 
excitement. 

The  prognosis  and  treatment  of  the  morbid  swindler  and 
liar  are  the  same  as  that  indicated  in  the  related  forms  of 
the  insanity  of  degeneracy.  Many  of  these  patients  cause 
so  much  trouble  that  they  require  permanent  custody. 

D.  The  Pseudoquerulants 

The  pseudoquerulants  comprise  a  group  of  morbid  per- 
sonalities whose  conduct  resembles  somewhat  that  of 
genuine  querulants  (see  p.  432),  but  who  never  develop 
genuine  delusions.  Whether  these  pseudoquerulants  com- 
prise a  uniform  group  is  undecided. 

The  intellectual  capacity  of  the  patients  is  usually  medi- 
ocre, but  is  sometimes  very  good.  As  a  rule  they  possess  a 
certain  craftiness,  which  enables  them  to  utilize  any  ad- 
vantage and  to  correctly  comprehend  the  weaknesses  of 
their  opponents;  some  show  a  tendency  to  quibbling  and 
hairsplitting.  Memory  is  generally  good,  however;  its 
accuracy  often  suffers  because  of  personal  coloring.  The 
memory  of  earlier  events  is  unconsciously  modified  in  accord 
with  their  emotional  needs.  Judgment  is  also  biassed, 
irrelevant,  tends  to  exaggerations,  is  in  many  ways  perverse 
and  influenced  by  intense  feelings.  Hence  persons  and 
conditions  are  often  incorrectly  judged.  Patients  them- 
selves are  often  uncommonly  credulous ;  that  is,  ideas  and 


532  FORMS  OF   MENTAL   DISEASE 

communications  which  correspond  to  their  tendencies  and 
views  are  considered  correct  without  further  proof,  but  if 
they  do  not  conform  to  their  desires,  the  patients  oppose 
them  with  the  most  extreme  and  obstinate  distrust. 

This  marked  personal  influence  over  apprehension,  mem- 
ory, and  judgment  arises  from  an  increased  emotional 
irritability.  The  patients  are  very  passionate  and  become 
greatly  excited  over  trifles.  They  regard  every  real  or  ap- 
parent infringement  upon  their  rights  as  gross  injustice, 
which  they  believe  themselves  justified  in  combating  with 
the  keenest  weapons.  They  are,  therefore,  revengeful  and 
persistent  in  their  hostility,  regard  every  opposition  as  a 
personal  matter,  are  always  ready  to  impute  to  their  adver- 
saries dishonorable  motives,  and  to  carry  on  their  fight  in 
every  possible  way.  Associated  with  their  passion  there  is 
a  marked  egotism.  Patients  regard  themselves  as  especially 
intelligent  and  superior  to  their  environment,  and  are  also 
disposed  to  consider  their  own  affairs  as  matters  of  public 
importance  —  that  they  themselves  are  champions  of  an 
important  cause.  Hence  even  trifling  affairs  lead  to  long- 
drawn-out  litigations,  because  they  feel  under  obligation  to 
fight  to  the  finish  for  their  rights.  The  combination  of  sen- 
sitiveness with  recklessness  and  arrogance  inevitably  in- 
volves patients  in  many  difficulties  and  conflicts  with  their 
environment.  There  arise  innumerable  misunderstandings 
and  provocations  which  gradually  involve  them  in  a  perfect 
maze  of  complications.  Patients  follow  up,  as  far  as  they 
possibly  can,  each  affair  with  bitter  determination.  They 
do  not  rest  with  the  judgments  which  are  handed  down, 
reject  favorable  settlements,  appeal  to  higher  courts,  and 
seek  to  interest  the  public  in  their  suits.  They  do  not  give 
up  the  fight  until  every  possibility  of  success  has  disap- 
peared; however,  they  sometimes  renounce  beforehand  the 


PSYCHOPATHIC  PERSONALITIES  533 

most  extreme  measures,  if  the  disproportion  between  the 
prospect  of  triumph  and  the  probable  cost  is  very  great. 
Then  they  attempt  to  obtain  satisfaction  in  other  ways, 
by  charges  of  forgery  against  the  witnesses,  who  have  not 
agreed  with  them,  or  by  petty  denunciations,  false  dealings, 
slanderings,  etc.  These  give  rise  to  new  controversies,  which 
only  increase  the  embitterment  and  develop  other  elements 
of  discord.  Meanwhile  there  develop,  in  one  way  or 
another,  petty  misdemeanors  which,  in  their  minds,  soon 
grow  to  be  occurrences  of  the  gravest  import.  Thus,  then, 
it  fairly  rains  complaints  and  counter  complaints  of  insults, 
claims  for  damages,  warrants,  examination  of  witnesses, 
trials,  legal  expenses,  attachments  without  number,  so  that 
patients  are  constantly  busy  in  one  court  or  another.  Their 
means  of  natural  livelihood  become  more  and  more  depleted. 
In  addition  to  their  vexations  and  constant  excitement  the 
demands  of  a  livelihood  come  in  to  increase  the  irritability 
and  embitterment  of  the  patients. 

The  development  of  this  condition  of  affairs  may  require 
ten  years  or  more.  There  is  progress  in  the  disease  only  in 
so  far  as  the  relations  of  the  patients  to  their  environment 
gradually  become  more  and  more  strained.  They  not  only 
feel  that  upon  every  occasion  they  are  treated  in  an  unfair 
and  hostile  manner,  but  they  also  think  their  neighbors  and 
acquaintances  are  angry  and  retaliating.  Thus,  there  are 
continuous  warfares  which,  because  of  their  contrary  dis- 
positions, are  being  constantly  incited  by  every  little  incident, 
but  they  never  go  as  far  as  to  form  true  delusions.  The 
patients  regard  their  opponents,  without  exception,  as  block- 
heads, trash,  and  scoundrels.  They  are  not  always  at  strife 
with  the  same  persons,  sometimes  this  one  and  sometimes 
that  one,  although  the  hostility  toward  certain  ones  may  be 
held  for  many  years.    The  same  occasion  does  not  always 


534  FORMS  OF  MENTAL  DISEASE 

serve  as  the  starting-point  for  all  the  controversies  that  arise 
later,  but  there  are  numerous  individual  occurrences,  which 
are  not  necessarily  related,  although  they  may  have  all 
arisen  from  the  same  source  of  personal  animosity.  In 
other  words  they  lack  the  subjective  bonds  which  unite  and 
draw  together  all  the  individual  experiences  into  a  continu- 
ous chain. 

Diagnosis.  —  The  pseudoquerulants  are  distinguished  from 
the  genuine  querulants  by  the  absence  of  genuine  delusion 
formation.  The  controversies  of  querulants  arise  only  from 
an  endeavor  to  obtain  expiation  for  an  injustice  originally 
inflicted  on  them,  and  which  appears  to  them  as  the  out- 
come of  hostile  persecution.  This  is  the  reason  why  they 
are  dissatisfied  with  the  court's  verdict,  regard  later  failures 
as  a  further  continuance  of  that  persecution,  and  resort  to 
the  most  desperate  measures  in  order  to  win.  In  pseudo- 
querulants there  is  nothing  of  this  kind.  The  patients 
usually  give  up  when  they  see  they  can  obtain  nothing  more, 
rarely  doubt  the  impartiality  of  the  courts,  and  come 
to  regard  them  as  accomplices  of  their  enemies  and  slander 
them.  They  forget  the  old  quarrels,  or  at  least  do  not  revive 
them,  and  are  not  always  striving  to  renew  investigations. 
The  circle  of  their  enemies  also  becomes  enlarged  as  a  result 
of  some  particular  personal  friction,  which,  however,  has  no 
delusional  connection  with  the  central  point  of  their  struggle. 
Not  infrequently  the  rights  of  the  pseudoquerulants  are 
maintained  by  the  courts  on  many  points.  This  also  is  an 
indication  that  their  contact  with  the  courts  is  not  influ- 
enced by  uniform  delusions.  Patients  are  usually  much 
the  worse  for  their  incessant  conflicts;  they  by  no  means 
carry  them  out  with  the  grim  satisfaction  which  is  afforded 
the  querulants  in  the  fulfilment  of  their  delusional  tasks. 
On  the  other  hand,  they  are  sometimes  rather  unhappy 


PSYCHOPATHIC  PERSONALITIES  535 

because  of  their  everlasting  troubles.  Occasionally  the  re- 
moval of  the  chief  source  of  trouble  by  some  change  in  the 
manner  of  living  may  produce  a  marked  improvement,  if 
some  other  occasion  does  not  arise  to  create  new  difficul- 
ties. As  the  patients  grow  older  they  become  dull  and 
indifferent,  but  on  the  other  hand  they  are  often  stubborn. 
Pseudoquerulants  never  develop  later  into  true  querulants. 
One  seems  justified  in  spite  of  their  external  similarities  in 
maintaining  that  they  represent  totally  different  conditions. 
Pseudoquerulancy  is  a  form  of  constitutional  endowment 
which  exists  from  youth  up  and  continues  without  essential 
change,  while  in  true  querulancy  we  have  a  disease  process 
which  begins  at  a  definite  time  and  runs  its  regular  course. 
There  is  a  sharp  line  between  psychopathic  pseudoquerulants 
and  the  ordinary  manifestations  of  those  persons  who  are 
irritable,  litigious,  and  obstinate. 

Treatment.  —  There  is  little  opportunity  for  efficient 
treatment  of  the  pseudoquerulant.  A  temporary  residence 
in  an  institution,  or  a  change  to  an  environment  which  is 
free  from  the  former  difficulties,  may  be  an  advantage.  In 
the  same  way  the  removal  of  the  chief  source  of  trouble  or 
the  friendly  intervention  of  trusted  persons  is  helpful.  Pa- 
tients do  not  do  well  without  some  restraint  of  their  liberty. 


XV.   DEFECTIVE   MENTAL  DEVELOPMENT 

Under  this  heading  are  described  those  mental  states 
which  are  the  result  of  an  incomplete  or  early  interrupted 
development  of  mental  life.  As  distinguished  from  the  pro- 
cess of  mental  deterioration,  these  states  may  be  regarded 
as  conditions  of  retarded  mental  development.  It  not 
infrequently  happens  that  both  conditions  exist  in  the 
same  individuals,  as  when  a  deterioration  psychosis  develops 
in  an  individual  with  defective  development. 

A  defective  hereditary  endowment  is  almost  always 
present.  The  pathological  basis  for  defective  mental  devel- 
opment is  the  incomplete  development  of  the  cerebral  cortex. 
This  is  often  due  to  some  disease  occurring  during  fetal  or 
infantile  life  which  has  an  injurious  influence  upon  the  devel- 
oping nervous  elements.  Our  knowledge  of  the  anatomical 
facts  is  as  yet  so  incomplete  that  it  is  impossible,  on  a  path- 
ological basis,  to  differentiate  between  the  different  grades 
of  defective  mental  development.  In  a  general  way  the 
lighter  forms  are  designated  imbecility,  and  the  severer 
idiocy. 

A.  Imbecility 

This  form  of  defective  mental  development  is  characterized 
by  a  moderate  degree  of  mental  incapacity  which  is  usually 
of  equal  prominence  on  all  sides  of  the  mental  life.  Clinically 
imbeciles  may  be  divided  into  two  groups,  the  stupid  and  the 
active,  according  to  the  degree  of  mental  activity. 

The  fundamental  symptoms  in  the  stupid  form  are  obtuse- 

536 


DEFECTIVE  MENTAL  DEVELOPMENT  537 

ness  and  stupidity.  There  is  an  inability  to  receive  many 
impressions,  or  to  grasp  and  utilize  the  experiences  of  life; 
consequently  the  knowledge  of  the  outside  world  confines 
itself  to  the  immediate  surroundings,  while  events  without 
the  patients'  narrow  mental  horizon  pass  unnoticed.  Prob- 
ably the  sensory  presentations  are  retained,  but  there  is  an 
absence  of  an  elaboration  of  individual  experiences  into  gen- 
eral ideas.  The  individual  and  insignificant  elements  make 
up  the  fund  of  experience.  Essential  and  fundamental 
relations  and  distinctions  are  not  recognized.  Thought 
is  scanty,  limited  mostly  to  daily  experiences,  usually  travels 
the  same  path,  and,  according  to  the  research  of  Buccola, 
is  really  retarded. 

Judgment  is  defective  and  uncertain,  and  often  determined 
by  chance  ideas  not  the  outcome  of  past  experience.  Pa- 
tients also  fail  to  consider  the  possible  consequences  of  their 
actions,  either  in  reference  to  themselves  or  others.  Memory 
is  accurate  only  for  the  most  prominent  events  of  life.  Yet 
sometimes  trifling  incidents  are  firmly  retained,  while  the 
more  essential  are  forgotten.  The  narration  of  events,  as 
remembered  by  them,  is  noticeably  faulty  because  of  nu- 
merous omissions  and  changes.  The  same  events  narrated 
at  different  times  show  many  contradictions,  though  some- 
times they  may  be  repeated  parrot-like.  Consciousness 
is  unclouded.  The  patients  recognize  the  surroundings  and 
comprehend  questions.  They  have  no  insight  into  their 
mental  condition,  but  usually  regard  themselves  as  per- 
fectly sound. 

In  the  patients'  actions  and  conversations  their  own  per- 
sonality always  comes  into  prominence.  The  central  point 
about  which  the  whole  life  revolves  is  their  own  physical 
well-being,  —  eating  and  drinking  and  the  possession  of 
things  desired,  —  while  all  else  is  indifferent.     Occasionally 


538  FORMS  OF  MENTAL  DISEASE 

they  fail  to  show  the  natural  affection  for  parents  and  rela- 
tives. The  superficial  sorrow  at  the  loss  of  some  relative 
is  quickly  lost  in  the  pomp  of  the  funeral  procession  and  the 
joy  over  a  new  suit  of  mourning.  The  absence  of  sympathy 
for  those  who  are  in  want  and  unfortunate  may  explain 
the  cruelty  which  they  sometimes  display  toward  animals 
and  in  their  combats  with  others. 

In  emotional  attitude  these  patients  are  indifferent,  apa- 
thetic, at  times  shy  and  anxious,  but  more  often  displaying  a 
simple,  childish  happiness.  Occasionally  patients  exhibit 
sudden  outbreaks  of  passion,  especially  if  irritated  or  if  they 
believe  themselves  misused.  In  conduct  they  are  usually 
harmless  and  tractable,  but  under  evil  influences  they  become 
ill-humored,  sometimes  stubborn  and  peevish.  The  sexual 
impulses  often  remain  wholly  undeveloped,  or  they  are  per- 
verted. Attempts  to  rape,  especially  children  and  even 
animals,  are  sometimes  observed.  Patients  are  incapable 
of  independent  activity,  yet  they  are  able  to  do  things  under 
supervision.  An  occasional  patient  shows  a  striking  tech- 
nical ability,  some  knowledge  of  music  or  a  certain  knack 
in  drawing,  —  but  even  this  knowledge  does  not  aid  them  in 
producing  valuable  work. 

Lighter  grades  of  this  type  of  imbecility  often  fail  of  recog- 
nition because  of  the  absence  of  sharp  border  lines  between 
them  and  the  stupidity  sometimes  present  in  normal  indi- 
viduals. Imbecilic  defects,  however,  become  more  and 
more  apparent  as  the  individual  advances  in  age  and  is 
compelled  to  take  up  some  responsibility  in  life.  Yet  these 
defects  may  not  be  recognized,  because  of  the  patients' 
ability  to  utilize  a  certain  amount  of  experience  and  to 
engage  regularly  in  a  simple  occupation.  But  just  as  soon 
as  anything  extraordinary  occurs, — a  mental  shock  or  a 
temptation  which  demands  discretion  and  decision  of  action, 


DEFECTIVE  MENTAL  DEVELOPMENT  539 

— the  mental  and  moral  incapacity  becomes  evident.  Un- 
fortunately at  this  time  their  actions  are  judged  from  a  legal 
and  not  from  a  medical  standpoint.  Rigid  military  dis- 
cipline brings  to  the  light  many  such  cases,  especially  in  those 
countries  where  military  service  is  required.  It  becomes 
most  apparent  in  stubbornness,  insubordination,  desertion, 
and  attacks  upon  officers.  Lack  of  judgment  in  handling 
these  cases  sometimes  results  in  suicidal  attempts. 

Imbecility  is  usually  recognized  at  an  early  date.  In 
infancy  it  may  be  noticed  that  patients  are  tardy  in  learning 
how  to  laugh,  to  imitate,  and  to  speak.  Later,  at  school, 
they  are  backward  in  studies,  are  sluggish,  indolent,  show 
poverty  of  thought  and  inability  to  comprehend,  and  soon 
become  the  sport  of  their  playmates.  They  find  difficulty 
in  learning  to  read,  write,  and  reckon,  and  the  few  facts  in 
geography  or  grammar  which  are  committed  to  memory 
are  soon  forgotten,  since  they  are  not  essential  to  their 
limited  experiences  of  life.  A  fairly  good  memory  may  con- 
ceal their  incapacity  for  a  long  time. 

The  patients  are  very  often  refractory,  hard  to  train,  and 
have  a  tendency  to  develop  bad  traits,  such  as  stealing, 
annoying  dumb  animals,  and  indulging  in  sexual  impro- 
prieties, which  often  necessitates  their  commitment  to  indus- 
trial schools.  During  youth  and  puberty  their  mental  in- 
capacity becomes  still  more  evident,  because  of  the  marked 
contrast  to  the  rapid  mental  development  of  their  play- 
mates. At  this  time  their  own  development  comes  to  a 
standstill  or  may  even  retrograde,  presenting  resemblances 
to  the  progressive  deterioration  of  dementia  precox. 

In  the  active  or  energetic  type  of  imbecility  there  is  a 
morbid  activity  of  the  attention  and  imagination,  in  contrast  to 
the  general  sluggishness  of  the  stupid  form.  Patients  are 
attracted  by  every  new  impression,  and  unable  to  direct  their 


540  FORMS  OF  MENTAL  DISEASE 

attention  permanently  to  any  one  object;  hence  their  ob- 
servations are  hasty  and  superficial.  They  are  always  ready 
to  pass  judgment  without  deliberation.  This  susceptibility 
to  new  and  accidental  impressions  renders  their  view  of 
the  outside  world  very  incomplete  and  fragmentary.  Such 
vague  pictures  lead  to  faulty  conceptions  and  form  the  basis 
for  incorrect  judgment.  Circumstances  existing  only  in 
their  imagination  are  of  far  more  importance  in  their  de- 
liberations than  absolute  facts.  Thought,  therefore,  becomes 
unsteady  and  shows  many  inconsistencies;  patients  vacillate 
in  their  plans  from  day  to  day,  draw  inconsistent  conclusions 
from  the  same  premises,  and  thus  their  views  of  life  and  the 
outer  world  lack  reality. 

Their  flighty  conversation  contains  a  frequent  repetition 
of  certain  high-sounding  remarks  and  commonplaces  which 
often  have  little  bearing  upon  the  sense.  They  are  very 
apt  to  lose  the  thread  of  conversation,  refer  to  the  most 
diverse  subjects,  but  usually  finish  with  some  very  striking 
remark.  Such  a  bombastic  style  very  often  conceals  from 
the  inexperienced  the  actual  mental  enfeeblement,  and  leads 
to  their  being  regarded  as  unusually  bright  individuals. 
It  is  quite  in  accord  with  these  mental  peculiarities  that 
patients  not  only  embellish  and  distort  their  recollections 
with  many  fanciful  ideas,  but  also  fabricate  extensively. 
In  spite  of  evident  contradictions  in  their  statements  they 
reassert  them  tenaciously  and  refuse  further  discussion.  Ac- 
cusations of  the  patients  against  relatives  and  fellow-patients 
should,  therefore,  be  accepted  with  the  greatest  caution. 
These  energetic  patients  possess  a  better  memory  than  the 
apathetic,  are  able  to  acquire  some  new  knowledge,  and  to 
adapt  themselves  to  new  environment  to  a  certain  extent. 

The  emotional  attitude  presents  a  mobility  equal  to  that 
encountered  in  the  attention  and  the  imagination.     Every 


DEFECTIVE  MENTAL   DEVELOPMENT  541 

impression  is  accompanied  by  an  accentuated  but  rapidly 
vanishing  tone  of  feeling,  and  the  moods  vacillate  from  one 
extreme  to  another,  showing  despondency  and  exuberance, 
despair  and  enthusiasm,  which  appear  upon  little  provo- 
cation. Violent  likes  and  dislikes  change  from  day  to  day; 
the  dearest  blessed  doctor  of  to-day  becomes  the  vilest  scoun- 
drel to-morrow.  While  extravagant  in.  their  emotional  ex- 
pressions, with  a  tendency  to  emotional  outbursts,  they 
are  readily  diverted  and  pacified.  Irritability  and  sensitive- 
ness are  always  present  to  a  greater  or  less  degree,  especially 
when  patients  believe  themselves  interfered  with;  often 
they  are  docile  and  good-natured.  An  exaggerated  feeling 
of  self-importance  regularly  accompanies  this  form,  some 
patients  even  believing  themselves  specially  endowed  and 
often  boasting  of  their  prospects,  while  at  the  same  time 
showing  a  lack  of  insight  into  their  diseased  condition. 
Any  shortcomings  on  their  part  are  explained  by  the  hos- 
tility of  relatives  or  lack  of  support. 

In  conduct  the  patients  are  odd,  freakish,  sometimes 
loquacious,  forward,  pretentious,  and  silly;  sometimes  quiet, 
docile,  and  reticent.  They  are  apt  to  dress  in  a  peculiar 
manner  or  to  be  slovenly  in  appearance.  They  work  with 
varying  zeal.  In  youth  they  are  frequently  considered 
bright,  especially  by  the  parents,  but  later  become  fickle, 
unable  to  employ  themselves  at  all,  leave  home,  wander 
aimlessly  about,  drink,  and  indulge  in  all  sorts  of  excesses. 
Many  prostitutes  belong  to  this  class.  In  many  of  these 
cases,  where  there  seems  to  be  only  a  light  grade  of  imbecility, 
there  may  be  some  question  whether  we  are  not  really  dealing 
with  conditions  of  degeneracy,  bat  the  presence  of  profound 
mental  deficiency,  in  spite  of  a  certain  amount  of  super- 
ficial activity,  should  leave  no  doubt.  Gudden  designated 
such  patients  as  "  high-grade  imbeciles." 


542  FORMS  OF  MENTAL  DISEASE 

Imbecility  may  form  the  basis  for  the  development  of  other 
psychoses;  as,  manic-depressive  insanity,  the  psychoses  of 
involution  and  dementia  praecox,  the  last  of  which  in  seven 
per  cent,  of  cases  appears  on  an  imbecile  basis.  Furthermore, 
it  often  happens  that  imbeciles  present  at  times  somo  of  the 
symptoms  characteristic  of  other  psychoses;  such  as,  periods 
of  excitement  and  depression, —  not  of  the  manic-depressive 
type, —  single  transitory  expansive  or  persecutory  delusions, 
occasional  hallucinations,  and  especially  the  attacks  charac- 
teristic of  the  constitutional  psychopathic  states.  Signs 
of  physical  degeneration  are  often  found  in  anomalies  of  the 
skull,  malformation  of  the  palate,  misshapen  ears,  puerile 
expression,  chorea,  etc. 

Course. — The  course  of  imbecility  is  quite  uniform; 
some  patients,  unsuccessful  in  their  attempts  to  enter  a 
profession  or  to  become  employed  in  mechanical  arts,  engage 
in  simple  labor,  and  failing  in  this,  they  become  a  burden  to 
the  family.  It  is  not  infrequent  for  them  to  develop  some 
psychosis  later  in  life, — forms  of  the  insanity  of  degeneracy, 
manic-depressive  insanity,  and  senile  dementia.  Others  show 
irregular  periods  of  excitement,  with  aggressiveness,  great 
irritability,  and  variable  emotional  moods.  Also,  the  various 
symptoms  of  epilepsy  not  infrequently  develop,  which  may 
also  lead  to  further  dementia.  In  some  of  these  cases  the 
signs  of  epileptic  dementia  predominate,  and  in  others  the 
epileptic  attacks.  Usually  it  becomes  necessary  at  some 
time  during  their  life  to  confine  them  in  almshouses  or  hos- 
pitals for  the  insane. 

Diagnosis.  —  There  are  some  cases  of  dementia  pmcox 
which  are  difficult  to  differentiate  from  the  lighter  active 
forms  of  imbecility.  The  character  of  the  onset,  dating  from 
childhood,  the  absence  of  hallucinations  and  pronounced 
delusions,  and  of  any  evidence  of  earlier  acquired  knowl- 


DEFECTIVE  MENTAL  DEVELOPMENT  543 

edge,  speak  for  imbecility.  Furthermore,  in  dementia  prae- 
cox  patients  may  show  some  improvement,  while  imbeciles 
present  no  change. 

There  are  a  few  cases  of  hysteria  with  a  moderate  degree 
of  deterioration  which  might  be  confounded  with  imbecility, 
but  in  them  the  course  of  the  disease  is  not  as  uniform  and 
the  mental  weakness  is  not  as  evident  on  all  sides  of  the 
psychical  life;  while  in  imbecility  but  few  patients  present 
hysterical  symptoms.  There  are  all  possible  transition  stages 
between  imbecility  and  the  normal  state,  among  which 
should  be  classed  those  weakminded  individuals  who  are 
overcredulous  and  superficial  in  knowledge,  getting  a  smat- 
tering of  everything,  but  knowing  nothing  thoroughly, 
who  take  hold  of  everything  new  with  enthusiasm,  are  easily 
led  astray  and  indulge  in  excesses,  and  who  are  always  in 
doubt  as  to  their  real  motives  for  action. 

Treatment.  —  The  treatment  of  congenital  imbecility 
consists  principally  in  providing  an  appropriate  education, 
with  a  view  to  developing  any  capacity  that  may  exist. 
This  is  best  accomplished  in  the  hands  of  some  competent 
tutor  or  in  a  private  or  state  institution  established  for  that 
purpose.  The  training  should  by  no  means  be  directed 
simply  toward  mental  education,  but  should  include  manual 
training.  The  use  of  alcohol  should  be  strenuously  avoided. 
The  removal  of  adenoids,  if  present,  even  though  they  may 
not  appear  to  impair  the  health  of  the  child,  is  highly 
essential.  Furthermore,  all  diseases  of  eyes  and  ears  should 
be  corrected.  If,  in  spite  of  training,  the  patients  develop 
dangerous  tendencies,  hospital  care  is  necessary. 


544  FORMS  OF  MENTAL  DISEASE 

B.  Idiocy1 

Idiocy  is  characterized  by  a  more  profound  degree  of 
mental  incapacity  than  imbecility. 

Etiology.2  —  Defective  heredity  is  one  of  the  most  impor- 
tant etiological  factors.  Idiocy  may  be  regarded  as  the  final 
stage  of  hereditary  degeneration.  Wildermuth  finds  defec- 
tive heredity  in  seventy  per  cent,  of  cases,  mostly  in  the  form 
of  alcoholism  in  the  parents.  Possibly,  also,  intoxication  of 
one  or  both  parents  at  the  time  of  copulation  predisposes 
to  idiocy.  Severe  illness  or  mental  shock  during  pregnancy 
and  hereditary  tendency  to  tuberculosis  (Piper)  have  been 
noted  as  causes.  Injuries  at  the  time  of  birth,  prolonged 
asphyxia,  but  especially  compression  by  narrow  pelves  or 
forceps  are  probably  important  factors.  In  idiocy  develop- 
ing after  birth  (one-fourth  to  one-third  of  cases)  the  most 
important  causes  are  infectious  diseases,  —  typhoid  fever, 
measles,  scarlet  fever,  and  diphtheria;  also  head  injuries, 
congenital  syphilis,  and  rachitis. 

Premature  ossification  of  the  cranial  sutures  is  no  longer 
regarded  as  a  cause  of  idiocy,  but  rather  as  an  accompani- 
ment, recent  investigation  showing  that  the  growth  of  the 
calvarium  is  determined  by  the  proportional  growth  of  the 
brain  and  not  vice  versa.  Malformation  of  the  cranium 
occurs  in  at  least  one-half  of  the  cases,  in  which  anomaly 
macrocephaly  is  far  more  prominent  than  microcephaly. 
An  extreme  grade  of  the  former  of  these  conditions  is  repre- 

1  Emminghaus,  Die  psychischen  Storungen  des  Kindesalters,  243  f. ; 
Sollier,  Der  Idiot  und  der  Imbecille,  deutsch  von  Brie,  1891;  J.  Voisin, 
L'idiotie,  1893 ;  Pellizzi,  Studii  clinici  ed  anatomo-patologici  sull'  idiozia, 
1901 ;  Bourneville,  Recherches  cliniques  et  therapeutiques  sur  l'epilepsie, 
l'hysterie  et  l'idiotie  (Regelmassige  Jahresberichte  iiber  die  Idiotenabtei- 
lung  des  Bicetre). 

7  Piper,  Zur  Aetiologie  der  Idiotie,  1893. 


DEFECTIVE  MENTAL  DEVELOPMENT  545 

sented  by  Plate  10,  Figure  1,  while  Figure  2  represents  the 
condition  of  microcephaly.  Furthermore,  the  early  closure 
of  the  suture  has  nothing  to  do  with  the  malformation  of  the 
brain.  Narrowness  of  the  base  of  the  cranium  accompanies 
more  often  the  profoundly  stupid  forms  of  idiocy,  and  small- 
ness  of  the  vertex  the  excited  forms.  More  than  one-half 
of  idiots  are  first-born,  and  four  to  five  per  cent,  are  twins. 
The  male  sex  predominates. 

Pathology.1 — Some  cases  present  defective  development  of 
the  central  nervous  system,  either  smallness  or  increased  size 
of  the  entire  encephalon  or  malformation  of  some  of  its  parts; 
absence  of  corpus  callosum,  of  cerebellum,  inequality  of 
hemispheres,  sparsity  or  anomalies  of  convolutions,  and 
microgyri,  which  conditions  represent  cessation  of  develop- 
ment, or  a  reversion  to  structures  characteristic  of  lower 
animals.  In  many  cases  evidences  of  genuine  disease 
processes  are  found,  particularly  encephalitis,  meningitis, 
hydrocephaly,  and  tumor  formation,  causing  extensive 
destruction  of  the  cortex  (porencephaly)  or  a  general  atrophy. 
Similar  conditions  may  be  due  to  vascular  changes,  of  which 
the  most  important  are  endarteritis,  thrombosis,  and  em- 
bolism; also  occlusion  of  vessels  caused  by  traumatic  hem- 
orrhage at  the  time  of  birth  or  later.  Syphilitic  disease,  either 
meningo-encephalitis  or  endo-arteritis,  may  lead  to  idiocy. 
Pupillary  disturbances  in  idiocy  are  usually  associated  with 
syphilis.    Bourneville  has  described  a  series  of  cases  of 

1  Hammarberg,  Studien  und  Klinik  und  Pathologie  der  Idiotie,  Deutsch 
von  W.  Berger,  1895;  Pfleger  und  Pilcz  in  Obersteiner's  Arbeiten, 
Heft  V,  1897;  Pilcz,  Jahrb.  f.  Psy.,  XVIII,  526;  Mingazzini,  Monatsschr. 
f.Psy.,  VII,  429;  Kotschetkowa,  Archiv  f.  Psy.,  XXXIV,  39;  Koppen, 
Archiv  f.  Psy.,  XXX,  896;  Konig,  Deutsche  Zeitschr.  f.  Nervenheil- 
kunde,  1897,  XI;  Anton,  Handbuch  der  patholog.,  Anatomie  des 
Nervensystems  von  Flatau-Jacobsohn-Minor,  416,  1904;   Weber,  Ibid., 

1440. 

2n 


546  FORMS   OF   MENTAL  DISEASE 

tuberous  hypertrophic  sclerosis,  which  are  characterized 
by  an  excessive  tumorlike  development  of  glia  following  an 
extensive  destruction  of  the  cortical  tissues. 

The  amaurotic  family  idiocy  described  by  Sachs  and  Tay 
occurs  almost  exclusively  among  Jews.  The  disease  develops 
during  the  first  two  or  three  years  of  life  in  healthy  children, 
is  accompanied  by  general  paralysis  and  atrophy  of  the  optic 
nerve,  and  always  terminates  fatally  in  a  few  months  or 
years.  While  the  real  nature  of  the  disease  is  still  unknown, 
it  is  probably  not  due  to  arrested  development,  but  to  an 
extensive  disease  process. 

Microscopically  we  may  find  either  an  insufficient  develop- 
ment of  the  neurones  or  evidences  of  former  disease  processes. 
In  underdevelopment  the  nerve  cells  do  not  develop  beyond 
an  embryonic  stage  (Hammarberg).  The  cortex  is  much 
thinner,  the  number  of  cells  is  reduced,  and  they  stand 
closer  together  in  regular  rows  with  much  less  gray  matter  be- 
tween them,  so  that  the  different  layers  cannot  be  clearly  dis- 
tinguished (a  characteristic  of  lower  animals).  The  cells 
themselves  are  embryonic  in  structure,  being  mostly  of  the 
same  size  and  globular  in  form.  The  degree  of  underde- 
velopment may  vary  in  different  parts  of  the  cortex.  (See 
Figure  1,  Plate  5.) 

In  other  cases  there  may  be  normal  development,  with  the 
usual  number  and  arrangement  of  cells,  but  in  areas  the 
cells  have  entirely  disappeared,  as  the  result  of  a  disease 
process,  and  the  glia  has  increased.  In  the  few  cases  of 
hypertrophic  sclerosis,  the  increase  in  the  size  of  the  brain 
is  due  to  the  great  increase  of  glia,  either  as  an  accom- 
paniment or  as  a  result  of  a  degenerative  process  in  the 
cortex.  The  nature  of  the  causes  which  produce  such 
lesions  in  fetal  and  early  life  is  still  unknown.  They  may 
be  due  to  intoxication  or  infection. 


Fig.  1.  —  Maerocephaly, 


Fig.  2. — Microcephaly. 


m     1 

■~*        M 

*%    **"      .» 

LA  v  1 

L      '  fl 

LJ 

Fig.  3.  Fig.  4. 

Figs.  3  and  4.  —  Representing  asymmetries  of  cranium  and  face. 
Plate  12 


DEFECTIVE  MENTAL  DEVELOPMENT  547 

Symptomatology.  — The  symptoms  of  the  disease  are  best 
considered  in  two  groups,  the  severe  and  the  light  forms. 
The  symptoms  of  the  former  correspond  to  the  mental  state 
presented  by  an  infant  during  the  first  days  following  birth, 
while  the  symptoms  of  the  latter  correspond  to  the  mental 
states  of  later  infancy. 

In  the  severe  cases  of  idiocy  patients  are  wholly  unable 
to  comprehend  external  impressions,  to  gather  experience, 
or  become  acquainted  with  the  environment,  to  form  clear 
ideas  or  judgments,  and  indeed  they  do  not  possess  self-con- 
sciousness. The  emotional  life  is  limited  to  mere  fluctua- 
tions of  the  general  feelings.  Consequently  the  impulses 
arising  from  these  feelings  lead  only  to  simple  actions,  such 
as  the  taking  of  food.  The  patients  have  no  choice  of  food 
and  eat  anything  placed  before  them,  even  to  pieces  of  cloth- 
ing and  rubbish.  Idiots  are  not  excitable;  they  show  very 
little,  if  any,  fear  or  pleasure,  at  the  most  manifesting  some 
pleasure  in  kicking  or  swaying  movements ;  while  hunger  or 
physical  pain  may  be  expressed  in  monotonous  or  shrill 
cries.  If  repeatedly  pricked  in  the  same  place,  causing  them 
to  cry  out  with  pain,  they  do  not  try  to  protect  themselves. 
Some  even  pound  themselves  and  inflict  severe  wounds, 
but  immediately  repeat  the  act.  One  girl  would  impul- 
sively bite  deeply  into  the  flesh  of  her  arm,  unless  pre- 
vented. 

Teething  is  delayed,  and  the  whole  physical  development 
retarded.  The  countenance  is  usually  stupid  and  vacuous. 
The  movements  are  clumsy  and  awkward;  patients  do  not 
walk  until  late,  and  some  never  even  learn  to  stand,  but  are 
absolutely  helpless.  Some  restlessness  may  develop,  with  a 
tendency  to  move  aimlessly  about,  to  sway  the  head  or  body 
back  and  forth  rhythmically  for  a  long  time,  to  clap  the 
hands,  or  to  grunt.     Convulsive  attacks  are  of  frequent 


548  FORMS  OF  MENTAL  DISEASE 

occurrence.  These  patients  are  so  utterly  helpless  that 
without  constant  attention  they  would  quickly  perish. 

In  thelight  cases  it  is  possible  to  fix  the  attention  momenta- 
rily by  the  aid  of  some  striking  object,  but  the  patients  them- 
selves are  quite  unable  to  direct  the  attention.  A  few  clear 
sensory  impressions  may  enter  consciousness,  and  a  limited 
number  of  ideas  may  be  formed,  which  are  extremely  simple, 
always  incomplete,  and  without  connection.  Memory  is 
very  poor ;  there  is  no  ability  to  make  a  selection  from  dif- 
ferent impressions  in  order  to  establish  a  basis  for  the  forma- 
tion of  concepts;  indeed,  a  psychic  personality  is  never 
developed.  Speech,  and  therefore  intercourse  with  the 
environment,  is  poorly  developed.  Unable  to  form  sen- 
tences, idiots  present  a  mixture  of  incomplete  words  or 
syllables  similar  to  the  early  efforts  of  an  infant.  They 
do  not  imitate,  play,  or  busy  themselves,  and  are  very  sus- 
ceptible to  fatigue. 

The  lower  sensory  or  selfish  feelings  dominate  the  emo- 
tional attitude,  and  liberate  only  those  impulses  for  action 
which  gratify  momentary  pleasure.  Idiots  never  feel  at- 
tracted toward  any  special  individual,  never  express  grati- 
tude, nor  show  grief.  When  irritated  by  rough  treatment 
or  opposed,  they  may  show  sudden  outbursts  of  rage,  at- 
tempting to  destroy  something  or  to  injure  some  one. 
Sexual  desires  may  either  remain  undeveloped  or  appear 
early  and  lead  to  reckless  masturbation  and  sexual  assaults. 
Often  the  appetite  for  food  is  abnormally  developed,  pa- 
tients eating  ravenously  and  feeding  themselves  with  their 
hands.  A  few  show  some  one-sided  capabilities,  such  as  a 
good  memory  for  numbers  or  words  or  some  very  simple 
technical  skill.     Many  idiots  are  fond  of  music. 

In  the  lighter  grades  of  idiocy  two  types  may  be  dis- 
tinguished, the  stupid  or  anergic,  and  the  excited  or  active, 


DEFECTIVE  MENTAL  DEVELOPMENT  549 

depending  upon  the  distractibility  of  the  attention.  The 
anergic  patients  are  torpid,  thought  is  sluggish  and  very 
limited,  and  there  is  pronounced  emotional  indifference. 
In  the  active  patients  the  attention  wanders  aimlessly, 
filling  consciousness  with  a  variegated,  incoherent  jumble. 
The  emotions  change  rapidly.  At  one  time  patients  are 
stubborn,  at  another  show  purposeless  activity,  running 
about,  laughing,  crying,  and  clapping  the  hands.  Between 
these  two  groups  there  are  numerous  transition  stages. 

In  idiocy  transitory  periods  of  excitement  or  depression 
may  occur  which  present  some  similarity  to  epileptic  excite- 
ment, attacks  of  manic-depressive  insanity,  and  the  excite- 
ment which  occurs  in  the  end  stages  of  dementia  prsecox. 
Compulsive  ideas,  morbid  impulses,  periods  of  anxiety,  some- 
times with  suicidal  tendencies,  may  appear,  and  occasionally 
there  may  be  simple,  childish,  expansive,  or  persecutory 
ideas. 

Physical  Symptoms. — There  is  a  stunting  of  the  whole 
physical  development;  the  stature  is  undersized  or  even 
dwarfish.  Countenance  is  childish.  Hair  is  often  absent 
from  the  face  and  pubes.  The  genitals  are  undeveloped; 
menstruation  absent,  late,  or  irregular.  Teeth  are  late  in 
developing  and  often  faulty  in  arrangement,  and  the  palate 
is  usually  asymmetrical.  The  special  senses,  especially 
hearing,  are  blunted.  In  eighty  per  cent,  of  cases  the  so- 
called  stigmata  of  degeneration  are  present  (Wildermuth), 
viz.  malformation  of  the  eyes,  ears,  mouth,  nose,  and  es- 
pecially the  bones  of  the  face.  Other  frequent  symptoms 
are  increase  or  loss  of  the  reflexes,  incoordination  of  the 
lower  extremities  and  of  the  eye  muscles,  and  difficulty  of 
speech,  with  elision  of  the  end  syllables,  stuttering,  halting, 
and  faulty  articulation  of  some  or  most  of  the  consonants. 
All  idiots  are  awkward  and  often  show  associated  move- 


550  FORMS  OF  MENTAL  DISEASE 

merits.  Mirror-writing  is  found,  especially  among  the  girls. 
Evidences  of  focal  cerebral  lesions  are  manifested  by 
hemiplegia,  paresis,  contractures,  convulsions,  choreic  and 
athetoid  movements,  aphasia,  and  in  thirty  per  cent,  of  the 
cases,  especially  in  boys,  epilepsy  (Wildermuth). 

Diagnosis.  —  The  recognition  of  the  disease,  which  is 
difficult  only  in  infancy  and  in  very  early  childhood,  depends 
upon  the  insensibility  of  the  children  to  external  influences. 
They  do  not  manifest  a  feeling  of  hunger,  even  when  lying 
upon  the  breast  or  at  the  approach  of  the  mother,  are  not 
attentive,  do  not  smile  or  cry,  and  may  be  continually 
restless;  many  give  evidence  of  some  cerebral  disturbance, 
as  paralysis  or  hemiplegia.  The  limbs  may  remain  in  a 
fetal  condition ;  they  do  not  learn  how  to  walk  or  talk,  and 
are  unable  to  understand  speech. 

Prognosis.  —  The  prognosis  is  unfavorable.  While  idiots 
can  never  reach  the  rank  of  normal  men,  the  question  of 
how  much  they  can  develop  is  of  great  importance.  In 
general  it  can  be  said  that  if  their  attention  can  be  held 
for  some  time,  and  they  give  evidence  of  memory,  i.e. 
recognize  articles  and  resist  what  they  have  once  experienced 
as  disagreeable  and  appear  to  understand  speech,  the 
prognosis  is  more  favorable.  The  appearance  of  epilepsy 
in  early  childhood  is  very  unfavorable.  During  puberty 
idiots  often  lose  what  little  knowledge  they  may  have  ac- 
quired, and  some  even  present  the  hebephrenic  or  catatonic 
picture  of  dementia  prsecox.  Their  life  is  usually  short, 
because  of  their  lessened  powers  of  resistance  to  intercurrent 
diseases. 

Treatment.  —  Temperance  in  parents  should  be  en- 
couraged as  an  important  prophylactic  measure.  The  con- 
dition of  faulty  nutrition,  which  is  frequently  present, 
improves  with  the  relief  of  insomnia,  the  prevention  of 


DEFECTIVE  MENTAL  DEVELOPMENT  551 

masturbation,  removal  of  sources  of  focal  irritation,  and 
strict  cleanliness.  Epileptic  attacks  should  be  combated 
with  bromids,  atropin,  or  other  suitable  measures,  with 
the  hope  of  preventing  profound  deterioration.  Crani- 
ectomy in  some  cases  of  microcephaly  is  an  irrational  pro- 
cedure and  is  fast  disappearing  from  practice. 

Besides  treatment  of  the  physical  condition,  the  patients 
should  receive  training  in  institutions  for  the  feeble-minded. 
Idiots  left  to  themselves  or  in  a  poor  environment  rapidly 
go  to  the  bad.  Harmless  patients  in  the  care  of  sisters  or 
brothers  may  become  threatening  or  aggressive  and  attempt 
sexual  assaults.  Such  patients  are  somewhat  susceptible 
to  training.  This,  however,  requires  a  greater  amount 
of  kindliness  and  patience,  and  more  experience  than  can  be 
obtained  in  the  ordinary  home.  An  effort  should  first  be 
made  to  teach  them  to  walk  and  use  their  hands,  also  to 
employ  their  different  senses,  to  direct  their  attention  and 
to  speak,  followed  by  special  instruction  in  the  perception 
of  objects,  in  distinguishing  them,  and  in  forming  simple 
judgments.  As  a  result  of  such  training,  many  patients 
yearly  leave  institutions  well  enough  trained  to  be  of  use  in  a 
limited  field.  They,  however,  continue  to  need  some  care 
and  supervision  throughout  life,  as  their  inability  to  get 
along  in  the  world  and  to  utilize  knowledge  stands  in  striking 
disproportion  to  knowledge  taught  them. 


INDEX 


Acquired  neurasthenia,  146. 

course,  153. 

diagnosis,  153 ;    from   congenital   neu- 
rasthenia, 155. 
from  dementia  paralytica,  153,  315. 
from  hebephrenia,  266. 
from  manic-depressive  insanity,  417. 

etiology,  146. 

physical  symptoms,  150. 

prognosis,  155. 

symptomatology,  148. 

treatment,  156. 
Activity,     78.     (See    pressure    of    activ- 
ity.) 
Acts,  compulsive,  90. 

impulsive,  90 ;  in  catatonia,  248. 
Acute  alcoholic  hallucinosis,  171,  189. 

course,  193. 

diagnosis,  193. 

etiology,  189. 

physical  condition,  192. 

prognosis,  194. 

symptomatology,  190. 

treatment,  194. 
Acute  cell  alteration,  282. 
Acute    confusional    insanity,    141.     (See 

amentia.) 
Agitation,  in  dementia  prsecox,  258. 

in  depressed  paretics,  312. 

in  melancholia,  355,  357. 
Agoraphobia,  503. 
Agostini,  437. 

Alcoholic    hallucinatory    dementia,    171, 
195. 

course,  196. 

diagnosis,  197. 

symptomatology,  195. 
Alcoholic  paranoia,  171,  195,  197. 

course,  199. 

diagnosis,  199. 

symptomatology,  197. 

treatment,  200. 
Alcoholic  paresis,  171,  200. 
Alcoholism,  162. 

acute,  162. 

chronic,  165.     (See  chronic  alcoholism.) 

in  dementia  paralytica,  279. 
Alcohol  pseudoparesis,  171,  201. 
Alzheimer,  137,  241,  370. 


Amaurotic  family  idiocy,  546. 
Amentia,  136,  141. 

course,  143. 

diagnosis,  144 ;  from  collapse  delirium, 
139. 
from  dementia  prsecox,  267. 

etiology,  141. 

physical  condition,  143. 

prognosis,  145. 

symptomatology,  141. 

treatment,  145. 
Anxiety,  in  melancholia,  354. 
Aphasia,  in  paresis,  294. 
Apprehension,  disturbances  of,   16,   104; 
in  manic  depressive  insanity,  382. 
Arrested  paresis,  318. 
Arteriosclerotic  insanity,  333. 

diagnosis,  338 ;   from  melancholia,  360. 
from  paresis,  338. 
from  senile  dementia,  379. 

pathological  anatomy,  334. 

severe  progressive  form  of,  337. 

symptomatology,  335. 

treatment,  341. 
Articulation,  disturbances  of,  294. 
Aschaffenburg,  125,  524. 
Associations,  external,  31. 

internal,  31. 

predicative,  31. 
Ataxia,  in  delirium  tremens,  180. 

in  paresis,  295. 
Atropin  delirium,  160. 
Attacks,  apoplectiform,  229 ;    in  paresis, 
292. 

epileptiform,  201,  229;  in  paresis,  291. 

epileptoid,  in  chronic  alcoholism,  168; 
in  delirium  tremens,  180. 

paralytic,  291. 
Attention,  18. 

active,  18. 

aimless,  18. 

blocking  of,  20. 

blunting  of,  19. 

distractibility  of,  21. 

disturbances  of,  18. 

in  amentia,  142. 

in  collapse  delirium,  138. 

in  delirium  tremens,  177. 

passive,  18. 


553 


554 


INDEX 


Attention  (Continued)  — 
passivity  of,  20. 

retardation  of,  20. 

suppression  of,  19. 

Automatism,  227,  245. 

Babinski  reflex,  296,  441. 
Raillarger,  7. 
Barrett,  328. 
Bechterew,  328. 
Befogged  states,  15,  465. 

determination  of,  105. 

hysterical  with  inconsequential  speech, 
468. 

hysterical  with  silly   excitement,   468. 

in  epileptic  insanity,  444. 
Blocking  of  the  will,  80. 
Blood   changes   in    dementia    paralytica, 

298. 
Bonhoeffer,  172,  173,  184,  189. 
Born  criminals,  515. 

diagnosis,  520. 

etiology,  517. 

symptomatology,  517. 

treatment,  521. 
Brain  abscess,  343. 
Bromism,  455. 
Busyness,  79,  392. 

Cabitto,  437. 

Capacitv  for  mental  work,  disturbances 
o'f,  57. 

Carbonic  acid  narcosis,  160. 

Carphologia,  123. 

Catalepsy,  83,  247. 

Catatonia,  241.  (See  dementia  pra?cox, 
catatonic  form.) 

Catatonic  excitement,  79,  248 ;  differen- 
tiated from  amentia,  144 ;  from 
collapse  delirium,  139  ;  from  acute 
delirium,  130. 

Catatonic  stupor,  80,  245;  differentiated 
from  post-infection  psychoses,  134. 

Cells,  plasma,  284. 

Cells,  rod-shaped,  284. 

Coll  sclerosis,  282. 

Cephalalgia,  in  acquired  neurasthenia,  150. 

Corea  flexibilitas,  83,  248. 

Cerebral  apoplexy,  symptoms  of,  343. 

Cerebral  hemorrhage,  symptoms  of,  343. 

Cerebral  syphilis,  326 ;  differentiation 
from  paresis,  318. 

Cerebral  trauma,  344. 
course,  346. 
insolation  in,  344. 
treatment,  347. 

Cerebral  tumor,  341. 

diagnosis,  343 ;  from  paresis,  318. 


Cerebral  tumor  (Continued)  — 

treatment,  343. 
Cerebropathia  psychica  toxamica,  134. 
Cerebrospinal  fluid,  103,  296. 
Charcot,  475. 
Childishness,  228. 
Chloroform  intoxication,  159. 
Chorea,  acute  delirium  of,  128. 

Huntingdon's,  324. 
Chorea  Magna,  458. 
Chronic  alcoholism,  165. 

diagnosis,  169. 

etiology,  165. 
pathological  anatomy,  165. 

prognosis,  169. 

symptomatology,  166. 

treatment,  169. 
Chronic  intoxication,  162. 
Chronic   nervous   exhaustion,    146.     (See 

acquired  neurasthenia.) 
Circumstantiality,  36,  385,  438. 
Classification  of  mental  diseases,  115. 
Cocain  hallucinosis,  acute,  211. 
Collapse  delirium,  136,  137. 

course,  138. 

diagnosis,   139;     from   acute   delirium, 
130. 
from  epileptic  befogged  states,   139. 

etiology,  137. 

pathological  anatomy,  137. 

prognosis,  139. 

symptomatology,  137. 

treatment,  139. 
Compulsive  insanity,  485,  498. 

course,  506. 

prognosis,  506. 

treatment,  506. 
Concepts,   disturbance   of  the  formation 

of,  29. 
Conduct  arising  from  a  morbid  basis,  95. 
Confusion,  42. 

characterized  by  flight  of  ideas,  43. 

combined  form  of,  43. 

desultory,  43. 

dreamy,  43. 

hallucinatory,  43. 

stuporous,  43. 
Congenital  neurasthenia,  146. 
Consciousness,  clouding  of,   14,  50,   105. 

clearness  of,  15. 

double,  59. 
Constitutional    despondency,    485,    492. 

course,  494. 

treatment,  494. 
Constitutional  excitement,  485,  495. 

diagnosis,  497 ;    from  hypomania,  497. 

treatment,  498. 
Contrary  sexual  instincts,  92,  485,  510. 


INDEX 


555 


Contrary  sexual  instincts  (Continued)  — 

course,  513. 

diagnosis,  513. 

etiology,  510. 

prognosis,  514. 

symptomatology,  511. 

treatment,  514. 
Constitutional  psychopathic  states,  470, 

485. 
Constraint,  243. 
Convulsions,  161,  547. 
Cortex,  gliosis  of,  323. 
Craniectomy,  551. 
Cravings,  insatiable,  463. 
Criminals,  509. 

born,  515. 

professional,  519. 
Crises,  in  phobias,  504. 
Cretinism,  216. 

etiology,  216. 

pathological  anatomy,  217. 

symptomatology,  217. 

treatment,  218. 

Dammerzustand,  15. 
Deceitfulness,  486. 
Dejection,  70. 

with  a  feeling  of  weariness  of  life,  71. 
Delbrueck,  526. 
Delinquente  nato,  516. 
Delire  de  negation,  353. 
Delire  du  toucher,  504. 
Delirium,  acute,  129. 
diagnosis,  130. 

anxious,  447. 

conscious,  448. 

occupation,  176. 
Delirium  tremens,  172. 

abortive  form  of,  179. 

course,  181. 

diagnosis,  182;     from   acute    alcoholic 
hallucinosis,  193. 
from  epileptic  befogged  states,  182. 
from  paresis,  182,  317. 

etiology,  172. 

pathological  anatomy,  173. 

prognosis,  182. 

symptomatology,  174. 

treatment,  182. 
Delusions,  48. 

expansive,  53,  233,  243,  263,  302,  307, 
396,  398,  425. 

fantastic,  54,  257,  365. 

hypochondriacal,  54,  351,  364,  403. 

nihilistic,  53,  353. 

of  infidelity,  198,  365. 

of  jealousy,  54,  197. 

of  mental  soundness,  55.     (<See  insight.) 


Delusions  (Continued)  — 

of  persecution,  53,  262,  312,  425. 
of  physical  influence,  262. 
of  self -accusation,  53,  311,  350. 
of  self-aggrandizement,  53. 
of  suspicion,  365. 
religious,  243. 
sexual,  54. 
somatic,  54. 
systematized,  52,  427. 
unsystematized,  52. 
Dementia,  acute,  136. 

simple  hypochondriacal,  231. 
Dementia  paranoides,  257.     (See  demen- 
tia precox,  paranoid  forms.) 
Dementia  paralytica,  276. 
agitated  form,  298,  307. 
course,  314. 

demented  form,  298,  299. 
depressed  form,  298,  310. 
diagnosis,  315;    from  acquired  neuras- 
thenia, 153. 
from    acute    alcoholic    hallucinosis, 

194. 
from    arteriosclerotic    insanity,  318, 

339. 
from  collapse  delirium,  139. 
from  delirium  tremens,  182. 
from  dementia  precox,  266,  270. 
from    Korssakow's    psychosis,    188. 
from  melancholia,  360. 
etiology,  276. 
expansive  form,  298,  301. 
pathological  anatomy,  280. 
pathology,  279. 
physical  symptoms,  290. 
prognosis,  318. 
symptomatology,  285. 
treatment,  319. 
Dementia  precox,  219. 
catatonic  form,  241. 
catatonic  form,  course,  252. 
catatonic  form,  diagnosis,  from  amentia, 
267. 
from  epileptic  befogged  states,  268. 
from  mania,  269. 
from  manic  stupor,  269. 
from  melancholia,  359. 
from  paresis,  266. 
catatonic  form,  physical  symptoms,  252. 
catatonic  form,  symptomatology,  242. 
diagnosis,  265 ;  from  acquired  neuras- 
thenia, 266. 
from  acute  alcoholic  hallucinosis,  194. 
from  alcoholic  hallucinatory  demen- 
tia, 197. 
from  manic-depressive  insanity,  416. 
from  paresis,  317. 


556 


INDEX 


Dementia  precox  (Continued)  — 

from  post  infection  psychoses,   133. 
from    presenile    delusional    insanity, 
368. 
etiology,  219. 
exacerbations  in,  255. 
hebephrenic  form,  230. 
hebephrenic  form,  course,  237. 
hebephrenic     form,     diagnosis,     from 

acquired  neurasthenia,  266. 
hebephrenic     form,     diagnosis,     from 
amentia,  267. 
from  imbecility,  272. 
hebephrenic  form,  physical  symptoms, 

237. 
hebephrenic    form,    symptomatology, 

231. 
paranoid  forms,  257. 
paranoid  forms,  course,  260. 
paranoid    forms,    physical    symptoms, 

260. 
paranoid  forms,  symptomatology,  257. 
paranoid  forms,  second  group,  260. 
paranoid  forms,  second  group,  course, 

264. 
paranoid  forms,  second  group,  symp- 
tomatology, 261. 
pathology,  221. 
physical  symptoms,  229. 
symptomatology,  222. 
treatment,  272. 
Depression,  constitutional,  419. 

with  a  flight  of  ideas,  410. 
Depressive  state  with  flight  of  ideas  and 

emotional  elation,  411. 
Derailment  of  the  will,  87. 
Desultoriness,  37,  40. 
Deterioration,  mental,  253. 
Dipsomania,  448. 
Disorientation,  26,  107. 
amnesic,  28,  107. 
apathetic,  27,  107. 
delusional  form  of,  28,  107. 
Disposition,  irritable,  66. 

sunny,  67. 
Distractibility,  57,  394. 

of  attention,  21. 
Double  consciousness,  59. 
Dread  neurosis,  480. 
course,  482. 

diagnosis,  482 ;  from   hysterical  insan- 
ity, 482. 
from  nervousness,  482. 
from  neurasthenia,  482. 
from  phobias,  483. 
treatment,  483. 
Drunkard's  humor,  168. 
Dual  personality,  58. 


Echolalia,  83,  228,  247. 
Echopraxia,  83,  228,  247. 
Ekmnesia,  59. 
Elsholz,  173,  181,  184. 
Embolism,  344. 

Emotional  attitude,   138,   143,   149,   178, 
192,  196,  204,  225,  235,, 244,  252, 
258,  260,  264,  289,  300,  305,  309, 
354,  366,  372,  375,  377,  379,  386, 
391,  398,  401,  429,  440. 
Emotional  deterioration,  63. 
Emotional  field,  110. 
Emotional  irritability,  diminution  of,  62. 

increase  of,  62,  110. 
Emotions,  disturbances  of,  62. 

morbid,  68. 
Energy,  specific,  3. 
Ennui,  74. 

Epidemics,  school,  458. 
Epilepsy,  psychic,  445. 
Epileptic  befogged  states,  444;   differen- 
tiated from  catatonia,   267 ;  from 
delirium  tremens,  182. 
Epileptic  furor,  440. 
Epileptic  insanity,  434. 

diagnosis,  450  ;  from  paresis,  450. 

etiology,  434. 

pathology,  436. 

physical  symptoms,  441. 

prognosis,  451. 

symptomatology,  438. 

treatment,  452. 
Epileptic  stupor,  446. 
Erichsen,  475. 
Erythrophobia,  502. 
Etat  crible,  335. 

Examination.     (See  methods  of  examina- 
tion, 97.) 
Excitement,  catatonic,  79. 

hysterical,  416,  469. 

motor,  78. 

periodic,  255. 
Exhaustion  psychoses,  136. 
Expression,  disturbances  of,  93. 
Eye,  motor  disturbances  of,  in  dementia 
paralytica,  293. 

Fabrications,  25,  185,  233,  287,  339,  372, 

375,  377. 
Fanaticism,  67. 
Farrar,  126. 
Fatigue,  74. 

increased  susceptibility  to,  57,  148,  149, 
286,  486. 

recovery  from,  57. 
Fear,  68. 

compulsive,  69. 

in  melancholia,  354. 


INDEX 


557 


Feeling  of  shame,  76. 
Feeling  of  well-being,  72. 
Feelings,  73. 
Fen§,  434. 
Fetichism,  92. 
Fever  delirium,  121. 

course,  123. 

diagnosis,  from  delirium  tremens,  182. 

etiology,  122. 

pathological  anatomy,  122. 

prognosis,  124. 

symptomatology,  122. 

treatment,  124. 
Flight  of  ideas.     (See  ideas,  flight  of.) 
Flightiness,  486. 
Folie  du  doute,  501. 
Frivolity,  morbid,  67. 
Fuerstner,  323. 

Gabiana,  278. 
Garbini,  278. 
Gianelli,  341. 
Gliarasen,  330,  371. 
Gliosis  of  cortex,  323. 
Gowers,  436. 
Grave  alteration,  282. 
Graves's  disease,  214. 
Grlibelsucht,  500. 
Gudden,  278,  541. 

Habitual  criminals,  524. 
Hagen,  7. 

Hallucinations,  3,  5, 10, 104, 137, 174, 189, 
198,  222,  232,  242,  258,  261,  286, 
300,  305,  309,  312,  352,  354,  365, 
372,  375,  378,  383,  396,  404,  428, 
438. 

dermal,  12. 

elementary,  4. 

microscopic,  13. 

muscular,  12. 

of  general  senses,  12. 

of  hearing,  11. 

of  memory,  25. 

of  sight,  11. 

of  smell,  12. 

of  taste,  12. 

psychic,  7. 

reflex,  9. 

stable,  of  Kahlbaum,  4. 
Hammarburg,  546. 
Hasheesh  delirium,  159. 
Headache,  290. 
Head  injury,  344. 
Hebephrenia,  230.      (See  dementia  prse- 

cox,  hebephrenic  form.) 
Hertz,  173. 
Hirschl,  165. 


Hoffman,  475. 
Homosexuality,  512. 
Horrors,  touch  of,  179. 
Humor,  drunkard's,  168. 
Hunger,  75. 
Huntingdon's  chorea,  296,  323. 

course,  324. 

diagnosis,  325. 

pathological  anatomy,  325. 

physical  symptoms,  324. 
Hydrophobia,  128. 
Hyperprosexia,  22. 
Hypersuggestibility,  247,  248. 
Hypnotism,  171,  474,  483,  514. 
Hypochlorization,  453. 
Hypochondriasis,  150,  311,  415. 
Hypomania,  390. 
Hysterical  constitution,  457. 
Hysterical  insanity,  457. 

course,  469. 

diagnosis,    470 ;    from   catatonia,   470. 
from  dementia  prsecox,  270. 
from  epileptic  insanity,  450. 
from  manic-depressive  insanity,  415. 

etiology,  458. 

pathology,  459. 

physical  symptoms,  464. 

prognosis,  470. 

symptomatology,  459. 

treatment,  471. 
Hysterical  lethargy,  467. 

Ideas,  compulsive,  33,  401. 

delusional,  364. 

disturbances  of  the  formation  of,  29. 

fixed,  51. 

flight  of,  37,  43,  385,  387,  390. 

hypochondriacal,  461. 

pessimistic,  308. 

simple  persistent,  34. 

store  of,  287. 

tormenting,  498. 
Idiocy,  544. 

diagnosis,  550. 

etiology,  544. 

pathology,  545. 

prognosis,  550. 

symptomatology,  547. 

treatment,  550. 
Ill-humor,  periodical,  443. 
Illusions,  3,  5,  10,  104,  137,  174,  372,  438 

apperceptive,  8. 

dermal,  12. 

muscular,  12. 

of  general  senses,  12. 

of  sight,  11. 

of  smeU,  12. 

of  taste,  12. 


558 


INDEX 


Imagination,  44,  287,  439. 

disturbances  of,  43. 

morbid  excitability  of,  30. 

simple  sluggishness  of,  44. 
Imbeciles,  high  grade,  541. 
Imbecility,  536. 

course,  542. 

diagnosis,  542 ;     from     hysteria,     543 ; 
from  dementia  priecox,  542. 

symptomatology,  536. 

treatment,  543. 
Impulsions,  498,  504. 
Impulses,  440. 

morbid,  91,  508. 
Impulsive  acts,  90. 
Impulsive  insanity,  485,  507. 

course,  509. 

diagnosis,  509  ;      from    compulsive    in- 
sanity, 509. 

treatment,  509. 
Impulsiveness,  488. 
Inadequacy,  feeling  of,  402. 
Indifference,  45. 
Infection  deliria,  121,  125. 

course,  127. 

outcome,  127. 

treatment,  130. 
Infection  psychoses,  121. 
Influenza,  128. 
Influenza  insanity,  121. 
Insanity,  compulsive,  33. 

epileptic,  434. 

hysterical,  457. 

impulsive,  485,  507. 

manic-depressive,  381. 

myxcedematous,  214. 

of  degeneracy,  485. 

post-epileptic,  445. 

pre-epileptic,  444. 

querulent,  432. 
Insight,  233,  251,  259,  288,  300,  309,  352, 
365,  372,  384,  402,  404,  439. 

absence  of,  55. 
Insomnia,  151,  156,  357,  362. 
Interference,  84. 
Intervals,  lucid,  413. 
Intoxication  psychoses,  159. 
Intoxications,  159. 
Involution  psychoses,  348. 
Irabundia  Morbosa,  66. 
Irritable  disposition,  66. 

Janet,  482. 
Jolly,  182. 
Judgment,   47,   108,    224,  235,  288,    366 

439. 
Jurgens,  328. 
Juvenile  Paresis,  277. 


Kahlbaum,  6,  7,  9,  88. 
Kaplan,  328. 
Keniston,  441. 
Kleptomania,  92,  508. 
Koppen,  346. 

Korssakow's  psychosis,  16,  24,  25,  28, 134, 
171,  183. 

course,  187. 

diagnosis,  188. 

etiology,  183. 

pathological  anatomy,  184. 

physical  symptoms,  187. 

symptomatology,  184. 

treatment,  189. 
Kraepelin,  220,  277,  278. 
Krafft-Ebing,  510. 
Kranisky,  437. 

Legrand  du  Saulle,  448,  501. 

Lesions,  focal,  in  dementia  paralytica, 
284. 

vascular,  in  dementia  paralytica,  283. 
Liar,  morbid,  526. 
Lombroso,  516. 

Macrocephaly,  544. 
Malaria,  delirium  of,  127. 
Mania,  390,  394. 
chronic,  418,  497. 
constitutional,  418,  497. 
course,  397. 
delirious,  390. 

course,  399. 

physical  symptoms,  399. 
grumbling,  408. 
irascible,  407. 
physical  symptoms,  396. 
unproductive,  408. 
Manic-depressive  insanity,  381. 
course,  412. 
delusional  form,  402. 
depressive  states,  400. 

course,  406. 

physical  symptoms,  406. 
diagnosis,  415. 

from  acute  alcoholic  hallucinosis,  194 

from  amentia,  144. 

from  collapse  delirium,  139. 

from  dementia  prsecox,  268,  269. 

from  melancholia,  358. 

from  paresis,  316. 

from  post  infection  psychoses,   133, 
134. 
duration,  413. 
etiology,  381. 
mania,  390. 
manic  states,  390. 
mixed  states,  407. 


INDEX 


559 


Manic-depressive  insanity  {Continued)  — 

nature  of,  382. 

prognosis,  417. 

simple  retardation,  400. 
course,  402. 

symptomatology,  382. 

treatment,  419. 
Manies  mentales,  498. 
Mannerisms,  86,  240,  249,  254. 
Marchand,  278. 
Marme,  205. 
Masochism,  92. 
Megalomania,  302,  307. 
Melancholia,  32,  348. 

course,  358. 

diagnosis,  358 ;  from  acute  neurasthenia, 
154. 
from    arteriosclerotic    insanity,    360. 
from  paresis,  315. 

from  post  infection  psychoses,   133. 
from  senile  dementia,  360. 

etiology,  349. 

pathological  anatomy,  349. 

physical  symptoms,  357. 

prognosis,  360. 

smaller  group,  352. 

symptomatology,  349. 

treatment,  361. 
Memory,  23,  178,  224,  234,  244,  286,  366, 
372,  384,  391,  429,  438. 

accuracy  of,  25,  106. 

disturbances  of,  23. 

fabrications  of,  106. 

hallucinations  of,  25. 

impressibility  of,  23,  106,  384. 

retentiveness  of,  23,  24,  106. 

retrospective  falsifications  of,  427. 
Mendel,  475. 
Menstrual  insanity,  255. 
Mental  elaboration,  disturbances  of,  23. 
Methods  of  examination,  97. 

anamnesis  of  the  disease,  98. 

family  history,  97. 

muscular  system,  100. 

personal  history,  97. 

status  prsesens,  99. 
Meyer,  A.,  328,  344,  346. 
Microcephaly,  544. 
Mcebius,  459. 
Moli,  165. 
Moll,  510. 
Monomania,  51. 
Mood,  change  of,  65. 
Moral  imbecility,  516,  520. 
Moral  insanity,  515,  516. 
Morbid  emotions,  68. 
Morbid  feelings  of  pleasure,  71. 
Morbid  frivolity,  67. 


Morbid  liar,  67,  526. 

diagnosis,  530. 

from  constitutional  excitement,  530. 
from  the  unstable,  530. 

prognosis,  531. 

symptomatology,  526. 

treatment,  531. 
Morbid  personal  peculiarities,  415. 
Morbid  swindlers,  67,  526. 
Morbid  temperaments,  65. 
Morphinism,  202. 

abstinence  symptoms  in,  205. 

course,  206. 

diagnosis,  206. 

etiology,  202. 

pathological  anatomy,  202. 

prognosis,  206. 

symptomatology,  203. 

treatment,  207. 
Morphin  intoxication,  acute,  203. 

chronic,  203. 
Motor  excitement,  78. 
Multiple  sclerosis,  326. 
Muscular  tension,  85,  246. 
Mutism,  88. 
Mysophobia,  503. 
Myxoedematous  insanity,  214. 

course,  215. 

etiology,  214. 

physical  symptoms,  215. 

symptomatology,  214. 

treatment,  216. 

Nausea,  75. 

Negativism,  88,  89,  227,  245,  246. 

Neologisms,  250. 

Nervous  dyspepsia,  152. 

Nervousness,  485. 

course,  490. 

diagnosis,  490;  from  neurasthenia,  490. 

treatment,  491. 
Nervous  weakness,  148. 
Neurasthenia.       {See     acquired     neuras- 
thenia, 146.) 

congenital,  146. 

sexual,  488. 
Neurocerebrite  toxique,  134. 
Nissl,  125,  164,  166,  174,  202,  209,  242, 
284,  331,  469. 

Onomatomania,  499. 
Opium  smoking,  159. 
Oppenheim,  475. 
Oppression,  feeling  of,  354. 
Organic  dementias,  323. 

Pain,  75. 

Paralysis  of  the  will,  77. 


560 


INDEX 


Paramimia,  228. 
Paramnesia,  25. 
Paranoia,  53,  423. 

course,  430. 

diagnosis,  431. 

from  dementia  praecox,  271,  431. 

erotic,  428. 

from  melancholia,  431. 

etiology,  423. 

prognosis,  432. 

religious,  428. 

symptomatology,  424. 

treatment,  432. 
Paresis,  276.     (See  dementia  paralytica.) 

ascending,  295. 

arrested,  318. 

tabo,  295. 
Peculiar  individuals,  66. 
Perception,  176. 

disturbances  of,  3,  104. 

falsifications  of,  17. 

phantasms,  4. 
Perplexity,  27. 
Perseveration,  35,  107. 
Personality,  dual,  58. 
Petite  mal,  346. 
Phobias,  69,  498,  502. 
Piper,  544. 

Pleasure,  morbid  feelings  of,  71. 
Pneumonia  delirium,  121. 
Porencephaly,  545. 
Practice,  57. 

Presbyophrenia,   16,  375;    differentiated 
from  Korssakow's  psychosis,  188. 
Presenile      delusional       insanity,      348, 
364. 

diagnosis,  367. 

etiology,  364. 

prognosis,  368. 

symptomatology,  364. 

treatment,  368. 
Pressure  of  activity,  78,  387,  392. 
Pritchard,  515. 
Pseudodipsomania,  524. 
Pseudohallucinations,  7. 
Pseudoquerulants,  531. 

diagnosis,  534. 

symptomatology,  531. 

treatment,  535. 
Psychic  epilepsy,  445. 
Psychic  hermaphroditism,  512. 
Psychic  weakness,  50. 
Psychogenic  neuroses,  457. 
Psychomotor  retardation,  80,  389. 
Psychopathic  personalities,  515. 
Psychopathic  states.     (<See  constitutional 

psychopathic  states.) 
Psychoses,  polneuritis,  134. 


Psychoses  (Continued)  — 

post-febrile,  121. 

post  infection,  131,  188. 
Pyromania,  93,  508. 

Reasoning,  disturbances  of,  47. 
Reflexes,  in  dementia  paralytica,  296. 

in  epileptic  insanity,  441. 
Relapses,  in  delirium  tremens,  181. 
Remissions,  301,  307,  310,  314. 

in  catatonia,  253. 

in  paresis,  314. 
Reperception,  6,  7. 
Resistance,  in  catatonia,  245. 
Rest  cure,  361. 
Rt'.stk'ssness,  362. 

nocturnal,  373. 
Retardation,  80,  389,  400,  404,  405. 

of  attention,  20. 

of  thought,  385. 
Richct,  453. 
Rigid  tension,  81. 

Sachs,  546. 
Sadism,  92. 
Sadness,  70. 
Santonin,  159. 
Schaefer,  296. 
Schrenk-Notzing,  510. 
Schiiles,  87. 
Schultzc,  475. 
Schuster,  342. 
Seclusiveness,  66. 
Self-accusations,  403. 
Self-aggrandizement,  53. 
Self-consciousness,  58. 

falsification  of,  60. 

splitting  of,  58. 
Self-depreciation,  53. 
Self-importance,  426. 
Senile  delirium,  377. 
Senile  delusional  insanity,  378. 
Senile  dementia,  24,  348,  369. 

diagnosis,  379 ; 

from  melancholia,  360 ; 
from  paresis,  318. 

etiology,  369. 

pathological  anatomy,  370. 

physical  symptoms,  374. 

severer  grade  of,  374. 

symptomatology,  371. 

treatment,  380. 
Senile  decay,  370. 
Senility,  379. 
Sensations,  false,  383. 
Sense  of  reality,  486. 
Sensibility,  17. 
Septic  states,  128. 


INDEX 


561 


Sexual  delusions,  54. 

Sexual  excitability,  76. 

Sexual  feelings,  76,  373. 

Sexual  feelings,  perverted,  76. 

Sexual  indifference,  76. 

Sexual  neurasthenia,  488. 

Simple  syphilitic  dementia,  326,  327. 

course,  328. 

diagnosis,   from  arteriosclerotic  insan- 
ity, 340. 
Simulation,  479. 

Smallpox,  initial  delirium  of,  126. 
Somatic  delusions,  54. 
Somnambulism,  446,  467. 
Speech,  180,  294,  387,  398,  442. 

explosive,  294. 

hesitating,  294. 

inconsequential,  250,  468. 

scanning,  294. 

slurring,  294. 
Spirit  possession,  263. 
Splitting  of  consciousness,  58. 
Spratling,  434,  437. 
States,  sad  and  anxious,  469. 

stuporous,  313,  405. 
Status  epilepticus,  455. 
Stereotyped  movements,  86. 
Stereotypy,  85,  227,  248. 
Strumpell,  475. 
Stubbornness,  89. 
Stupor,  catatonic,  80. 

manic,  410;    differentiated  from  cata- 
tonia, 417. 
Subsultus  tendinum,  123. 
Suggestion,  simple,  474. 
Suicide,  356,  363. 
Sully,  25. 

Superfluous  embellishment,  87. 
Swindlers,  morbid,    67.     (See    morbid 

swindlers  and  liars.) 
Swindlers,  529. 
Syphilis,  278. 
Syphilitic  pseudoparesis,  326,  329. 

course,  330. 

diagnosis,  331 ;  from  senile  dementia, 
379. 

pathology,  330. 

physically,  329. 

treatment,  332. 

Tabetic  psychoses,  332. 
Tabo-paresis,  295. 
Tay,  546. 

Temperature,  252,  297. 
Tension,  muscular,  85. 

rigid,  81. 
Thought,  178,  224,  234,  244,  263,  305,  309, 
352,  354,  366,  371,  385,  438. 
2o 


Thought  (Continued)  — 

acceleration  of,  56. 

circumstantiality  of,  107. 

confusion  of,  42. 

desultoriness  of,    107.     (See    desultori- 
ness.) 

disturbance  of  the  rapidity  of,  56. 

paralysis  of,  31,  107. 

rambling,  38. 

retardation  of,  32,  56,  107. 

train  of,  107. 
Thrombosis,  344. 
Tics,  494. 
Tobacco,  72. 
Tormenting  ideas,  498. 
Toulouse,  453. 
Tramps,  529. 
Transitions,  414. 
Traumatic  delirium,  344,  345. 
Traumatic  dementia,  344,  345. 
Traumatic  hysteria,  475. 
Traumatic  insanity,  primary,  345. 
Traumatic  neuroses,  457,  475. 

diagnosis,  479. 

from     constitutional     psychopathic 

states,  479. 
from  hysterical  insanity,  479. 

etiology,  475. 

physical  symptoms,  477. 

prognosis,  479. 

symptomatology,  476. 

treatment,  480. 
Typhoid  delirium,  121. 
Typhoid  initial  delirium  of,  125. 

TJlrichs,  510. 
Unconsciousness,  15. 

determination  of,  105. 
Unpleasant,    increased   susceptibility    to 

the,  65. 
Unstable,  the,  521. 
diagnosis,  525. 

from  born  criminals,  525. 
from  hysteria,  525. 
from  dementia  prsecox,  525. 
symptomatology,  521. 
treatment,  526. 

Vasomotor  disturbances,  297. 

Verbigeration,  95,  251. 

Visions,  104. 

Voice  of  conscience,  105. 

Voices,  internal,  12. 

Volitions,  77. 

Volitional  impulses,  crossing  of,  85. 

diminution  of,  77. 

facilitated  release  of,  81. 


562 


INDEX 


Volitional  impulses  (Continued) 
impeded  release  of,  79. 
increase  of,  78. 

Wanton  happiness,  72. 
Warm  bath,  prolonged,  140. 
Weariness,  prolonged,  148. 
Weigert,  284. 
Well-being,  feeling  of,  72. 
Wernicke,  184. 


Westphal,  475. 

Wildermuth,  434,  435,  436,  544,  549,  550. 

Wilfulness,  463. 

Will,  blocking  of,  80. 

diminished  susceptibility  of,  88. 

distractibility  of,  84. 

heightened  susceptibility  of  the,  83. 

hypersuggestibihty  of,  83,  227. 

paralysis  of,  77. 

weakness  of,  83. 


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Text-Book  of  Comparative  Anatomy. 
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to  the  English  Translation  by  Professor 
Dr.  Ernst  Haeckel,  F.R.S.,  Director 
of   the    Zoological    Institute   in   Jena. 


Translated  into  English  by  HENRY  M. 

Bernard,      M.A.      (Cantab.),     and 

Matilda    Bernard.     8vo.     Cloth. 

Illustrated. 

Part  I.    pp.  xviii  +  562. 


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LILIENTHAL 


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Imperative  Surgery.  For  the  General 
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LOCKWOOD 

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MACDONALD 

A  Treatise  on  Diseases  of  the  Nose 
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MACEWEN 

Pyogenic  Infective  Diseases  of  the 
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By  the  Same  Author 

Atlas  of  Head  Sections.  Fifty-three 
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MACLAGAN 

Rheumatism:  Its  Nature,  Its  Pa- 
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MACMILLAN'S  Manuals  of  Medicine  and 
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A  Manual  of  Diseases  of  the  Skin.  By 
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A  Text-Book  of  Surgical  Pathology. 
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The  Application  of  Physiology  to  Medi- 
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A  Manual  of  Chemical  Physiology  and 
Pathology.    By  T.  G.  P.rodie,  M.D. 
A  Manual  of   Surgical    Anatomy.     By 
Francis  C.  Abbott,  M.S. 
Diseases  of  the  Nose,  Throat  and  Ear. 
By  Di-ndas  Grant,  M.D.,  F.RC.S. 
The  Essentials  of  Morbid  Anatomy.    By 
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The  Principles  of  Pathology.  By  B. 
Abrahams,  M.D. 

Medical  Diseases  of  Childhood.  By  J.  A. 
Coltts. 

MACPHERSON 

Mental  Affections.  An  Introduction 
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The  Nervous  System  and  the  Mind. 
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MIGULA 

An  Introduction  to  Practical  Bacteri- 
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Technical  High  School  of  Karlsruhe. 
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Edited  by  H.  J.  Campbell,  M.D., 
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Muscle,  Brain  and  Diet :  A  Plea  for 
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MTJIR  and  RITCHIE 

Manual  of  Bacteriology.  Bv  Robert 
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The  Elements  of  Vital  Statistics. 
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OPPENHEIM 

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PERCIVAL 

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Atlas  of  External  Diseases  of  the  Eye. 
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REBMANN  and  SEILER 

The  Human  Frame  and  the  Laws  of 
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REYNOLDS 

Hygiene  for  Beginners.  By  Ernest 
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A  Primer  of  Hygiene.    Illustrated. 

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ROLLESTON  and  KANTHACK 

Manual  of  Practical  Morbid  Anatomy. 
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ROOSA 

Defective  Eyesight:  The  Principles 
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SCHAFER 

Text-Book  of  Physiology.  Edited  by 
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Vol.  II.    499  Illustrations,    pp.  xxiv  +  1365. 
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SHEILD 

A  Clinical  Treatise  on  Diseases  of  the 
Breast.  By  A.  Marmaduke  Sheild, 
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SMITH 

Introduction  to  the  Outlines  of  the 
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Atlas  of  Nerve-Cells.  By  M.  Allen 
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STEPHENSON 

Epidemic  Ophthalmia,  Its  Symptoms, 
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STONHAM 

A  Manual  of  Surgery.  By  Charles 
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Surgeon  to  the  Westminster  Hospital ; 
Lecturer  on  Surgery  and  on  Clinical 
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SUTER 

Handbook  of  Optics.  For  Students  of 
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THOMA 

Text-Book  of  General  Pathology  and 
Pathological  Anatomy.  By  Richard 
Thoma,  Professor  of  General  Pathology 
and  Pathological  Anatomy  in  the  Uni- 
versity of  Dorpat.  Translated  by 
Alexander  Bruce,  M.A.,  M.D., 
F.R.C.P.E.,  F.R.C.S.E.,  Lecturer  on 
Pathology,  Surgeons'  Hall,  Edinburgh ; 
Pathologist  to  the  Royal  Hospital  for 
Sick  Children ;  Assistant  Physician  and 
formerly  Pathologist  to  the  Royal  In- 
firmary, Edinburgh.  Volume  I.  With 
436  Illustrations.  8vo.  Cloth,  pp. 
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THORNE 

Diphtheria :  Its  Natural  History  and 
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TUBBY 

Deformities.  A  Treatise  on  Orthopae- 
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TUBBY,  M.S.  (Lond.),  F.R.C.S.  (Eng.), 
Assistant  Surgeon  to,  and  in  charge  of, 
the  Orthopaedic  Department,  Westmin- 
ster Hospital ;  Surgeon  to  the  National 
Orthopaedic  Hospital,  etc.  Illustrated 
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Notes  of  100  Cases.  8vo.  Sheep. 
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TURNER 

Hints  and  Remedies  for  the  Treatment 
of  Common  Accidents  and  Diseases, 
and  Rules  of  Simple  Hygiene.  Com- 
piled bv  Dawson  W.  Turner,  D.C.L. 
Revised,  Corrected,  and  Enlarged  by 
twelve  Eminent  Medical  Men  belong- 
ing to  different  Hospitals  in  London, 
and  by  one  Right  Rev.  Bishop  of  the 
Established  Church,  formerly  Surgeon 
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WORKS  ON  MEDICINE  AND  5. 


UNNA 

The  Histopathology  of  the  Diseases 
of  the  Sinn.    By  Dr.  P.  G.  Unna. 

Translated  from  the  German,  with  the 
assistance  of  the  Author,  by  Norman 
Walker,  M.D..F.R.C.P.  (Ed.),  Assist- 
ant Physician  in  Dermatology  to  the 
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tions in  the  text.  8vo.  Cloth,  pp. 
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VERWORN 

General  Physiology :  An  Outline  of 
the  Science  of  Life.  By  Max  Ver- 
WORN,  M.D.,  Ph.D.,  A.O.,  Professor 
of  Physiology  in  the  Medical  Faculty 
of  the  University  of  Jena.  Translated 
from  the  Second  German  Edition  and 
edited  by  Frederic  S.  Lee,  Ph.D., 
Adjunct  Professor  of  Physiology  in 
Columbia  University.  With  285  Illus- 
trations. 8vo.  Cloth,  pp.  xvi  +  615. 
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WARING 

Manual  of  Operative  Surgery.  By  H. 
J.  Waring,  M.S.,  M.B.,  B.Sc.  (Lond.), 
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Senior  Demonstrator  of  Anatomy  St. 
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WARING 

Diseases  of  the  Liver,  Gall  Bladder, 
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By  H.  J.  Waring,  M.S.,  B.Sc.  (Lond.), 
F.R.C.S.,  Demonstrator  of  Operative 
Surgery,  and  Senior  Demonstrator  of 
Anatomv  St.  Bartholomew's  Hospital, 
etc.  8vo.  Cloth.  58  Illustrations. 
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WARNER 

Three  Lectures  on  the  Anatomy  of 
Movement.  A  Treatise  on  the  Action 
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By  the  Same  Author 

The  Nervous  System  of  the  Child: 
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and  Lecturer  at  the  London  Hospital, 
etc.     i2mo.     Cloth,    pp.  xvii  4-  233. 

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The  Study  of  Children  and  Their 
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WATSON 

Practical  Handbook  of  the  Diseases 
of  the  Eye.  By  D.  Chalmers  Wat- 
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Marshall  Street  Dispensary,  Edin- 
burgh; late  Clinical  Assistant,  Oph- 
thalmological  Department.  Royal 
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Plates  and  24  Illustrations  in  the  text. 
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WEBSTER 

Diseases  of  Women.  A  Text-Book  for 
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F.R.C.P.  (Ed.),  Demonstrator  of  Gynae- 
cology, McGill  University;  Assistant 
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ures. 121110.  Cloth,  pp.  xxii  +  688. 
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WHITE 

A  Text-Book  of  General  Therapeutics. 
By  W.  Hale  White,  M.D.,  F.R.C.P., 
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turer on  Materia  Medica  and  Thera- 
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WIEDERSHEIM 

The  Structure  of  Man :  An  Index  to 
His  Past  History.  By  Dr.  R.  Wie- 
DERSHEIM,  Professor  in  the  University 
of  Freiburg,  Translated  by  H.  and  M. 
Bernard.  The  Translation  edited 
and  annotated  and  a  Preface  written  by 
G.  B.  Howes,  F.L.S.,  Professor  of 
Zoology,  Royal  College  of  Science, 
London.  105  Illustrations.  8vo. 
Cloth,    pp.  xxi  +  227.    Price  $  2.60  net. 

WILLIAMS 

The  Roentgen  Rays  in  Medicine  and 
Surgery  as  an  Aid  in  Diagnosis,  and 
as  a  Therapeutic  Agent.  By  Francis 
H.  Williams,  M.D.  391  Illustrations. 
8vo.    Cloth,    pp.  xxx  +  658. 

Price  $  6.00  net. 
Half  morocco.     Price  $  7.00  net. 

WILLIAMSON 

Diabetes  Mellitus  and  Its  Treatment. 
By  R.  T.Williamson,  M.D.  (Lond.). 
M.R.C.P.,  Medical  Registrar,  Manches- 
ter Royal  Infirmary;  Hon. Med. Officer, 
Pendleton  Dispensary ;  Assistant  to  the 
Professor  of  Medicine,  Owens  College, 
Manchester.  With  18  Illustrations. 
8vo.     Cloth,     pp.  xi  +  417. 

Price  $  4.50  net. 

WILLOUGHBY 

Handbook  of  Public  Health  and  De- 
mography. By  Edward  F.  Wil- 
LOUGHBY,  M.D.  (Lond.),  Diploma  in 
State  Medicine  of  the  London  Univer- 
sity and  in  Public  Health  of  Cambridge 
University.  i6mo.  Cloth.  pp. 
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WILSON 

The  Cell  in  Development  and  Inherit- 
ance.   By  Edmund  B.  Wilson,  Ph.D., 


S 


WORKS   Oh   MEDICINE  AND  SURGERY 


Professor  of  Zoology,  Columbia  Uni- 
versity. Second  Edition,  Revised  and 
Enlarged.  8vo.  Cloth.  194  Illustra- 
tions, pp.  xxi-r-483-  Price  $  3.50  wrf. 
By  the  Same  Author 

An  Atlas  of  the  Fertilization  and  Kar- 
yokinesis  of  the  Ovum.  By  Edmund 
B.  WILSON,  Ph.D.,  Professor  in  Inver- 
tebrate Zoology  in  Columbia  Univer- 
sity •  with  the  co-operation  of  EDWARD 
Lemming,  M.D.,  F.R.P.S.,  Instructor 
in  Photography  at  the  College  of  Physi- 
cians and  Surgeons,  Columbia  Univer- 
sity.   Royal  4to.    Cloth. 

Price  $  4.00  net. 

WILSON 

Clinical  Studies  in  Vice  and  in  In- 
sanity. By  George  R.  Wilson, 
M.D.,  Medical  Superintendent,  Mans- 
bank  Asylum.  8vo.  Cloth,  pp.  a  + 
234.  Price  $  3.00  »rf. 

WORSNOP 

The  Nurse's  Handbook  of  Cookery ;  A 
Help  in  Sickness  and  Convalescence. 
By  E,  M.  Worsnop,  First-Class    Di- 


plomee  of  the  National  Training  School 
of  Cookery,  South  Kensington,  and  for 
sixteen  years  Teacher  of  Cookery  under 
the  London  School  Board.  Assisted 
bv  M.  C.  Blair.  Second  Edition. 
i2mo.    Cloth,    pp.  106.    Price  75  cents. 

ZEEGLER 

A  Text-Book  of  Special  Pathological 
Anatomy.  Bv  Ernst  Ziegler,  Pro- 
fessor of  Pathology  in  the  University 
of  Freiburg.  Translated  and  Edited 
from  the  Eighth  German  Edition,  by 
Donald  MacAlister,  MA,  M.D., 
Linacre  Lecturer  of  Physic  and  Tutor 
of  St  John's  College,  Cambridge,  and 
Henry  W.  Cattell,  M.A.,  M.D., 
Demonstrator  of  Morbid  Anatomy  in 
the  University  of  Pennsylvania.  8vo. 
562  Illustrations. 

Sections  I-VIII.  pp.  xix-f-  575  +  **&•  M 
Cloth,  Price  $4.00  net. 
Sheep,  Price  $  5.00  net. 

Sections  IX-XV.  pp.  xv  +  576-1221  +  xxxi. 
Cloth,  Price  $  4.00  net. 
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